
J7vHtT?m 



J. HENRY DOWD, M, 4 




m^ 




ERRATA. 



Unfortunately through hasty proof reading several 
typographical errors are observed. In several instances 
this is noticeable regarding the most common words 
and which have been used many times throughout the 
work. The following are among the corrections to be 
made : 



Page xviii, 14, 23, 


urethral instead of uretheral. 


7, 




albumin ' 


1 albumen. 


k ' 17. 




alkaline ' 


4 alkali. 


" 25, 




cannibalistic ' 


canabalistic. 


" 3°« 




and ' 


although. 


" 3i, 




neuclei ( 


neucli. 


" 34, 




involvement 


' involvment. 


" 36, 


No. 5. 


Usually ' 


always. 


" 45, 




Bellevue ' 


Bellevieu. 


" 45, 


5o, 92, 


cachexia ' 


4 cacexia. 


" 62, 




ducts are ' 


duct is. 


" 73, 




pathognomonic ' 


pathognomic 


44 80, 




soiled ' 


4 soiling. 


44 82, 




fear ' 


4 fever. 


44 107 




cicatritial 


cicitritial. 


" 117 




urethral ' 


4 internal. 



A PRACTICAL TREATISE ON 

SIMPLE 

AND 

CHRONIC SPECIFIC 
ITRETPIRITIS. 

By 
J. HENRY DOWD, M. D. 

Late Gen ito- Urinary Surgeon Buffalo Hospital Sisters of Charity, ex-Chairman 

Surgical Section Buffalo Academy of Medicine, Member Medical 

Association of Central New York, Etc., Etc. 

ILLUSTRATED. 




BUFFALO, N. Y. 

A. W. LANDSITTEL. 

1901. 




THE LIBRARY OF 

CONGRESS, 
Two Cop»E8 Received 

JUN- 18 1901 

Copyright entry 

CLASS <^XXc. N». 

COPY 8. 



Copyright, 1901. 
By J. Henry Dowd, M.D. 



TO 
THE LATE 

SPENCER C. DeVAN, M. D., 

SURGEON, U. S. M. H. S., 

I dedicate this small volume, 

in kind remembrance of the interest taken 

in me 

while serving as his house surgeon, 

also for the many pleasant 

hours spent in his 

company. 

THE AUTHOR. 



INTRODUCTION. 

So numerous are the works that have appeared with- 
in the last two or three years dealing with diseases of 
the mucous membrane ot the male urethra that it seems 
almost a waste of time to try to improve, or bring forth 
anything new. In each one of these a chapter or more 
may be found devoted exclusively to what is known as 
chronic gonorrhea, gleet or urethritis, and simple ure- 
thritis is considered, but generally very briefly. The 
young man, and even the old one, procures these latest 
publications, carefully studying every word, the know- 
ledge gained therefrom being applied to cases on hand, 
or to the first one applying for relief. What is the in- 
variable result ? Simply a prolongation of the trouble, 
and in the large majority of cases exaggerating the con- 
dition over that presented by the patient at the first call. 
Many times I have heard the remark, " I have used the 
very latest treatment, and it only seems to make the 
condition worse. What is the trouble ? " To this I 
always reply, "You have overtreated the case." My 
assertion has been proven, for when a rest of a couple 
of weeks has been enforced, and the condition again 
treated on rational basis, the result has been but one, a 
rapid resolution of the inflamed membrane. In most 
books nothing, and in others very little, is snd as to 



VIII INTRODUCTION. 

when a specific (gonorrheal) urethral inflammation is be- 
yond infection. Cases of this description are usually a 
nerve strainer to most medical men, but, taking into 
consideration that the Germans tell us that at least 85 
c /c of the operations on the female generative organs 
are brought about by gonorrhea, no one can be excused 
for being in ignorance as to when a gonorrheal inflam- 
mation is cured ; that is, beyond infection. Yet, how 
many pay attention to this ? The patient has reported 
week in and week out, possibly for months, with that 
same morning drop. If, by some lucky chance, a strong 
injection suddenly stops the discharge the physician 
considers himself fortunate, and at once discharges the 
patient, although the washings of the urethra would 
show any amount of dequamation going on, any, or por- 
tions of which, if subjected to careful microscopical ex- 
amination, would demonstrate the presence of cocci, 
capable of producing inflammation but not having the 
strength to continue a free secreticn in the possessor. 
This is readily understood— they have been multiply- 
ing, and I might say fighting, for months to continue an 
existence on soil rendered barren by their long inhabi- 
tation. The patient, wishing to avoid a repetition of his 
experience, marries. These cocci, which have been 
found in the urethral debris, instead of being washed 
out by the urine, are forced from the canal at the time 
of sexual intercourse and land at but one place — against 
the cervix. Here virgin soil is encountered, and they 



INTRODUCTION. IX 

at once take on new life, causing inflammatory condi- 
tions which as a rule have but one ending, a miserable 
existence for the possessor with ultimate mutilation. 
The question may arise, Do not these v. omen or their 
husband know that an infection has taken place ? Why 
should they ? The germs have been placed against an 
organ almost insensible to pain, and at least four inches 
from a surface that might be bathed by urine, which 
might give them the sensation (as in the male) of ardor- 
urinas. Furthermore, between the infected locality and 
the meatus urinaris there is a barrier lined by epithelium 
that wdll almost withstand an attack of fire. Inhabiting 
this tube, if such it ma)' be called (vagina) are bacteria 
which nature seems to have placed here for the protec- 
tion of the delicate organs above from an invasion by 
bacteria of a virulent nature. In other words, these 
normal vaginal bacteria, although perfectly harmless to 
their possessor, seem to act in a cannibalistic manner to 
other germ life. The reason that women rarely know 
that they are infected is readily expla nable. For a 
woman to have symptoms of gonorrhea, L e., symptoms 
similar to those in the male, infection must take place at 
the vulva. The most important reason for its non-ap- 
pearance here is the fact that when the discharge is 
coming from the male in quantities sufficient to exude 
from the urethra and be deposited at the vaginal open- 
ing the man in question usually has a chordee of a 
severity that prohibits sexual intercourse. It is only 



X INTRODUCTION. 

when this chordee has almost if not entirely disappeared 
and with it the discharge, that he attempts intercourse. 
At this time there is only a drop that can be brought 
forward by pressure along the canal, but with ejacula- 
tion it is forced out and against the cervix. It seems 
almost a paradox, but the woman infected in this way 
does not present the disease again to her partner ; still 
if she seeks a second male companion he usually is in- 
fected. 

Although my readers may think this a very exhaustive 
treatise on what has always been considered so trivial a 
disease, still I cannot help but say that from a wide ex- 
perience in hospital and private practice I cannot retract 
one word that has been written. Simple urethritis has 
been dealt with most exhaustively for the reason that 
but little mention is made of this trouble in most text 
books. It must be acknowledged that in a previously 
healthy urethra inflammation rarely occurs, but as it does 
occur occasionally, patients with such a condition should 
be given a correct diagnosis ; but furthermore and more 
important, it may save a person from the loss of a good 
name. 

The urine has been considered in connecticn with 
this subject for the very good reason that if one wants 
to bring about a normal state in a membrane which is 
interruptedly bathed with a fluid they must have some 
knowledge of the make-up of this fluid, not only in 
health but in disease. It has been the author's aim not 



INTRODUCTION. XI 

to give a lengthy description of the urine, but rather to 
give a sort of epitome of the same to an extent sufficient 
to have a good working knowledge when dealing with 
disease of the urinary tract, especially in the conditions 
treated of in this work. Knowing that this work will in 
all probability fall into the hands of the younger mem- 
bers of the profession, that class to whom most of the 
patients flee to for relief, the writer has written without 
going minutely into detail, and has endeavored, as far 
as is practical, to give in chapter XIX. a condensed list 
of instruments, chemical solutions, microscopical appli- 
ances, stains, etc., necessary, not only for urinary work 
but also for operations on the urethra and adjacent 
parts. 

J. HENRY DOWD, 
378 Franklin Street, 

Buffalo, N. Y. 
May, 1901. 



CONTENTS. 



PAGE- 

Introduction. vii 

Illustrations. 

CHAPTER I. 

THE URINE. 

General remarks, necessary examination, 
amount, specific gravity, reaction, odor, color, 
transparency, albumin, glucose, urea, indican, 
chlorides. 7 

CHAPTER II. 

THE URINE. 

Crystals, phosphates, oxalates, uric acid, 
casts, epithelium, Carpenter's description of 
genito-urinary epithelium, pus, blood, spermat- 
ozoa, mucus, tubercle bacilli, other bacteria, 
molds, fission fungi, mucous cylinders. 18 

CHAPTER III. 

SIMPLE URETHRITIS. 

Definition, causes, bacteria present, Noegg- 
rath's statement regarding gonorrhea, Plate I, 
normal urethral cocci, explanation of plate. 28 



CONTENTS. . XIII 

CHAPTER IV. 

SIMPLE URETHRITIS. 

Symptoms, report of case, diagnosis, the mi- 
croscope, pus cocci, Lustgarten's pseudo gon- 
ococci, advice in medico-legal cases, treatment, 
author's injection for acute gonorrhea, summary, 
hand syringe (cut.) 36 

CHAPTER V. 

CHRONIC SPECIFIC URETHRITIS. 

Synonyms, definition, Otis's opinion, time 
chronicity is established, when a cure is com- 
plete, exacerbations, cause of. 40 

CHAPTER VI 

CHRONIC SPECIFIC URETHRITIS. 

Causes. Early and persistent interference, 
localized inflammatory areas, granulations, 
stricture, earliest appearance of the same, lo- 
cation of strictures, shreds in urethral contrac- 
tion, urethrometer as a diagnostic agent, infllam- 
mation around stricture tissue. 47 

CHAPTER VII. 

CHRONIC SPECIFIC URETHRITIS. 

Causes (continued. )Contraction ofthenavic- 



XIV CONTENTS. 

anemia, constitutional conditions, report of case 
of tubercular involvement, cancer, Bright's dis- 
ease, diabetes, syphilis, tuberculosis. 51 

CHAPTER VIII. 

CHRONIC SPECIFIC URETHRITIS. 

Causes (continued.) Lithemia, faulty diges- 
tion, prostatic or vesicular involvement, follic- 
ulitis, idiosyncrasy, want of tone in the tissue, 
society man, constitutional cachex : as, chronic 
renal trouble. 5$ 

CHAPTER IX. 

CHRONIC SPECIFIC URETHRITIS. 

Clinical evidence (symptoms) of, locating 
site of inflammation by aid of urine, prostatic in- 
volvement, subjective symptoms, indication of 
vesicular involvement, spermatorrhea venereal 
warts, involvement of the caput gallinaginis. 63 

CHAPTER X. 

CHRONIC SPECIFIC URETHRITIS. 

Diagnosis. Physiology of urination, the two 
glass test, as urine becomes clearer, semen in 
urine, tests for posterior urethral involvement, 
Ultzmann's syringe for use, secretion at mea- 
tus, postatorrhea, Bcettcher's crystals, ure- 
throrrhea 69 



CONTENTS. XV 

CHAPTER XI. 

CHRONIC SPECIFIC URETHRITIS. 

Infectiousness, pus producing cocci, staphylo- 
cocci, streptococci, gonococci, microscopical 
examination of shreds, plate II, the streptococ- 
ci, explanation plate II, prognosis. 76 

CHAPTER XII 

CHRONIC SPECIFIC URETHRITIS. 

Urethral antisepsis, bacteria found in urine 
and urethra, conclusions as regards catheters, 
etc., report of case, Ultzmann syringe, plate 
III, staphylococci, explanation plate III. 87 

CHAPTER XIII. 

CHRONIC SPECIFIC URETHRITIS. 

History, importance of careful questioning, 
leaf from author's history book. 89 

CHAPTER XIV. 

CHRONIC SPECIFIC URETHRITIS. 

Treatment for first visit, searching for cause, 
formula for astringent injection, observation of 
case as to constitutional condition, appearance 
of shreds in a chronic case, posterior urethra, 



XVI CONTENTS. 

best mode of using syringe, Ultzmann's, plate 
IV, gonococci, explanation plate IV. 98 

CHAPTER XV. 

CHRONIC SPECIFIC URETHRITIS. 

Treatment (continued.) Formula of zinc 
alum solution, silver solution, table as to 
strength of silver solutions, office treatment, 
use of zinc alum solution, passage of instru- 
ments, early and persistent interference, the 
older the condition the quicker the cure, thick- 
ened membrane, granulations. 105 

CHAPTER XVI. 

CHRONIC SPECIFIC URETHRITIS. 

Treatment (continued.) Stricture, amount 
of dilation at each visit, when stricture is cur- 
able, navicular valve as an obstruction, when 
steel instruments should be used, rubber in- 
struments, changes following dilation, bloody 
shreds, when cutting is necessary, mode of re- 
laxing spasm, opening in stricture, navicular 
valve and small meatus, anemia and constitu- 
tional conditions, tuberculosis, diabetes, can- 
cer, Bright's disease and syphilis, climate for 
tubercular patients. 113 



CONTENTS. XVII 

CHAPTER XVII. 

CHRONIC SPECIFIC URETHRITIS. 

Treatment (continued.) Lithemia, copabia, 
santalwood oil and cubebs, bathing, rheuma- 
tism, prostatic or vesicular involvement, use of 
psychrophore, Dr. Guiteras' prostatic douche 121 

CHAPTER XVIII. 

CHRONIC SPECIFIC URETHRITIS. 

Treatment (continued.) Folliculitis, occular 
attachment, description of necessary instru- 
ments, diseased follicles, how recognized, solu- 
tion for destruction of, Otis electric lamp (au- 
thor's attachment), idiosyncrasy, types, differ- 
entiation from anemia, etc., internal medica- 
tion in, climate, urine in, tone in bloodvessels, 
prescription, diet in, injections for, sounds in, 
want of tone in the tissues, gastro-intestinal 
secretion, exhaustion, avoidance of, tonics in, 
diet and general instructions, coitus, liquor, 
tobacco, diet, etc., summary of chronic speci- 
fic urethritis 129 

CHAPTER XIX. 

Apparatus necessary for the diagnosis and 
treatment of pathological conditions of the 
urinary tract, for the urine, microscopical, 
chrmicals. 135 



XVIII CONTENTS. 



ILLUSTRATIONS. 



URETHRAL SYRINGE. 33 

ULTZMANN SYRINGE, 



with author's attachment. 



80 



THE OTIS ELECTRIC LAMP. 123 

with the author's optiaal attachment. 

PLATES. 

No. i Normal uretheral cocci and bacteria 

mucus and epthelium. 27 

No. 2. Streptococci, pelvic epith. pus, blood. 73 

No. 3. The staphylococci, pus, epithelium. 84 

No. 4. The gonococci, mucus, pus, epithel. 97 



CHAPTER I. 

THE URINE. 

Although it will be impossible in this brief work to go 
minutely into detail regarding the urine, yet a general 
knowledge of its composition in health and disease must 
be familiar to those hoping to bring about resolution in an 
inflamed membrane that is interruptedly bathed with this 
fluid. In many a case of gonorrhea rebellious to treat- 
ment a cause is at times found in a urine heavily charged 
with urates or uric acid. It is in the chronic conditions 
and especially with complications that we find this fluid 
one of our most valuable aids in diagnosing existing con- 
ditions, locating cause and even in giving a prognosis. 

For the average case an examination like the following 
will be found very useful, but space will only permit of an 
epitome, leaving my readers to consult any good work on 
urinary analysis for further knowledge: 

Amt.24 hours., Sp.G.,Reac, Opaque, Albu., Sugar, 

Urea, grs. 24 hours. Iudican, Chlorides. 
MICROSCOPICAL, 

CRYS. Phos.,Oxal, Uric acid, Amor., Phos., Urates. 

CASTS Hyaline. Epithelial, Waxy, Granular, Blood. 

EPITH.Post. Ureth., Bladder, Ureters, Pelvic, Tubul. 

SEDIMENT Pus, Blood, Mucus. Spem'so., T ub. bac, 

other bacteria, Mucous cylinders. 

The average urinary secretion for 24 hours is stated to 



2 SIMLPE AND SPECIFIC URETHRITIS. 

be between 45 and 50 ounces, but this is liable to great 
variation. In the summer there is less secreted on ac- 
count of free perspiration, while on the other hand there 
is an increase in cold weather. The ingestion of foods 
or liquors, especially the alcoholic beverages increase it 
and to a marked degree, at times. Extreme nervousness 
always increases it. A good plan is to esLmate about 2 
and 1 -4th ounces as being the average hourly secretion 
during the day. On seeing the patient have him empty 
the bladder, at the same time ascertaining when he passed 
urine last. If suppose four ounces is passed in, say, 
one hour, of a watery color and eliminating Bright 's 
disease, Diabetes and nervousness, we may with a fair 
degree of certainty accuse him of partaking of diuretics, 
possibly liquor, within three hours. 

SPECIFIC GRAVITY. This is normally between 
1 015 and 1022, but it varies greatly and is in no way 
a positive indication of any disease. The gravity will 
be increasd or decreased according to the amouut of 
solids dissolved therein; thus, pus will not increase, where 
, urea or urates will, it being found at times as high as 
1035 an d yet no pathological condition may be present. 

Two or three glasses of beer will in an hour or more 
produce a urine having a gravity of 1010 or even 1006 
still the kidney may be perfectly healthy- Generally 
speaking, when there is no special pathological condition 
present, a high specific gravity is due to an excess of 
uric acid, urea or urates and these at times acting cs an 



THE URINE. 3 

important factor in continuing the inflammatory process. 

REACTION. Freshly passed normal urine shouldbe 
acid in reaction. This at times in perfect health may 
be altered to a pronounced alkalinity. Neutral urine is 
never observed under normal conditions. Alkalinity is 
occasionally seen as a constant condition being present at 
any and all times of the day, where, on the other hand it 
is present in some persons only after a meal, especially 
if vegetables have been partaken of freely. In old 
chronic inflammations along the urinary track, an alkaline 
urine may be constantly present. Alkalinity as hyper- 
acidity is very often a serious drawback to resolution. 

Dickman says, "They are nervous and mobile, of a 
hypochondrical temperment having half gouty character- 
istics*" 

ODOR. Although this is of little or no consequence, 
freshly passed urine if amouical is usually an indication 
of bacterial decomposition m the bladder. This condi- 
tion is as a rule due to some obstruction near the neck, 
most important being stricture or enlarged prostate. 

Many foods and drugs impart to the urine a charac- 
teristic odor, examples of such being turpentine, aspara- 
gus and celery. 

COLOR. Normal urine should be amber colored, (such 
as is on the mouthpiece of expensive pipes), but like the 
other characteristics this varies even in health. Diet, 
weather and nervousness play an important part in chang- 
ing the color, which may vary all the way from that of 



4 SIMPLE AND SPECIFIC URETHRITIS. 

water to a dark brick red. When owing to free per- 
spiration or the patient having a severe cold, a dark red 
is the rule. The color of the urine is always changed 
in disease, especially of the urinary tract. The most 
common is that of diluted milk, this being due to pus. 
Occasionally in the absence of inflammation, it is of an 
imitation amber hue, this being caused by urea, uric 
acid or urates in excess. In regard to results, this 
color, although not exactly normal, is the most favorable 
to find in cases of chronic urethritis. 

TRANSPARENCY, Freshly passed urine, when 
normal, is perfectly transparent. If this is varied, i. e., 
any opacity exists, some abnormality must be present. 
Visual examination is important in every case and as 
will be shown later phosphaturia, vesiculitis, localization 
of ure thritis and even urethral contractions can be diag- 
nosed with a fair chance of correctness. Turbidity of 
the urine is due to the following causes, which occur in 
the order of frequency named: PUS, PHOSPHATES, 
BACTERIA, SEMEN, MUCUS, EPITHELIUM, 
BLOOD, OXALATES, URIC ACID AND URATES. 

ALBUNIN. It has been and still is a much debated 
question whether serum albumin occurs in the urine 
under normal conditions. Some maintain that it can be 
found in the urine of perfectly healthy young adults, as 
after a cold bath, mental labor and during menstruation. 
Albumin is the coagulation of blood serum (as a rule), and 
this fluid escaping from the vessels anywhere along the 



THE URIl 5 

urinary tract will give rise to the r$l n. It must not 
therefore be supposed that albumm c es only from the 
kidneys. If seminal or prostatic fluid is mixed in the 
urine, and even at times in the course of bladder and 
urethral inflammation, albumin is found ; still in the case 
of the former this is said to be nucleo-albumin. It is 
generally conceded by authors that albumin is always 
found in pyelitis, although at times it is present in such 
small quantities that the finest test is called for in its de- 
tection. At the same time blood corpuscles are quite evi- 
dent, especially if in the acute condition, or during an 
exacerbation. Albumin is not always an accompani- 
ment of nephritis, unless in the acute condition, which 
generally means the parenchymatous variety. It is also 
present in the chronic form of the latter, but interstitial 
nephritis may or may not be accompanied by albumin, 
generally not. 

GLUCOSE. Sugar is in no way a symptom of inflam- 
mation of the urinary organs, but if diabetes compli- 
cates a case of gonorrhea it is very necessary that its 
presence be known as it (the disease) may seriously in- 
terfere w 7 ith recovery. This substance, as that of albu- 
min, has received much careful study and investigation 
as to whether or not it can occur in normal urine. The 
consensus of opinion now is that sugar (glucose) is 
found in^ normal urine, but in such small quantities that 
its presence is only detectable by the very finest tests 
and is net characteristic ot any pathological condition. 



6 SIMPLE AND SPECIFIC URETHRITIS. 

UREA. " This is the most important nitrogenous con- 
stituent of the urine, representing under normal condi- 
tions from 85 to 86 % or the total amount of nitrogen 
eliminated by the kidneys.'"— Simon. The remainder 
(nitrogen) is excreted as uric acid, hippuric acid, etc. 
It is not positively known when urea is formed, but 
from numerous experiments it is supposed to be in the 
large glands, such as the liver and spleen and not in the 
kidneys, as was at one time supposed, for, after removal 
of the latter, urea has been found in the blood and tis- 
sues. It must not be supposed that pathological condi- 
tions can in any way be accurately determined by the 
amount of urea eliminated, for on the one hand the nit- 
rogen may be markedly eliminated as uric acid and thus 
urea be greatly diminished, where, on the other, the re- 
verse may be present. In cases of nephritis, where it 
is supposed to be diminished to a marked degree, I have 
found it much in excess of the estimated daily amount, 
yet both patients were at the time dying, having marked 
uremic symptoms. To have a positive result of the 
amount of nitrogen eliminated it is necessary that the 
amount of nitrogen-bearing elements be known. 

INDICAN. During intestinal putrefaction Indol which 
is formed is oxidized in the blood to Indoxyl. This, 
combining with sulphuric acid, is eliminated as Indican. 
By careful research it has been definitely determined 
that Indican is formed solely in the presence of micro- 
organisms and that its only source is the large intestines 



THE URINE. 7 

In pathological conditions this substance is increased. 
Such may be mentioned intestinal jfutref action, ac- 
companied by indigestion (intestinal), carcinomata of the 
stomach, acute, subacute and chronic gastritis, acute 
and chronic peritonitis, pyelitis and many other diseases 
in connection with or involving the gastro-intestinal 
tract. Simon in his book says that it is as important to 
test for indican as it is for albumen or sugar, and that 
points of decided importance, not only in diagnosis but 
also prognosis, may be gained. 

CHLORIDES. The chlorides found in the urine are 
derived almost entirely from the food and occur chiefly 
as sodium chloride. They are found in varying amounts 
from ii to 15 grms. per 24 hours. This amount is 
greatly varied in diseases, at times being almost entirely 
absent They are decreased in all febrile diseases with 
the exception of intermittent fever. In this condition 
they are decreased, but not to the extent as in other 
febrile conditions. It is said that the chlorides are 
diminished according to the severity of the acute febrile 
condition existing. By this it may be assumed that 
during such a febrile condition an increase of this urin- 
ary constituent would mean an improvement in the con- 
dition. One author says that a continued increase over 
15 to 20 grms. in 24 hours is pathognomic of diabetes 
insipidus. 



CHAPTER II. 

THE URINE. 

MICROSCOPICAL APPEARANCE. 

CRYSTALS. The various crystals like phosphates, 
oxalates, uric acid, together with their companions the 
amorphous variety, are frequently seen in apparently 
normal urine; especially is this true of the amorphous 
salts. Little dependence can be placed in them as a 
diagnostic symptom, yet, when they are constantly present, 
they usually indicate some systemic derangement, but 
further, and most important, they at times act as a factor 
in prolonging inflammatory conditions of the urinary 
tract. 

PHOSPHATES. The earthy phosphates con- 
sist of two varieties (a) triple or ammonio-magnesium 
phosphate, and (b) calcium phos. or phosphate of lime. 
The former, although assuming different modifications, 
have two distinct forms [i] coffin shaped, and [2] the star 
shaped, feathery crystals. The second, calcium phos- 
phate, appears either as crystals, which are very rare, or 
amorphous, being very common. The latter when seen 
in the urine gives it a greenish-white appearance, is 
readily dissolved by acids and when allowed to settle 
forms in a solid like mass in the bottom of the glass, 
much resembling fine white sand. It is this substance 
that gives the opacity to the urine when boiled and unless 



THE URINE. 9 

acid be added for dissolving might simulate albumen. 
There is no special disease characterized by phospha- 
turia. They are found in connection with irritative 
affections of the prostate and bladder, general debility, 
convalescence from acute diseases, despondency, and in 
certain individuals after every meal. Roberts says : 
" Crystaline phosphate of lime is an accompaniment of 
some grave disorder, such as cancer of the pylorus, 
phthisis and exhaustion from obstinate chronic rheu- 
matism." 

OXALATES. These occur in either alkaline or acid 
urine, most commonly the latter. When it is found in 
acid urine it is usually associated with uric acid, where, 
if present in alkaline urine, phosphates are usually asso- 
ciated with it. They always occur as crystals and in 2 
forms (a) octahedral, and (b) dumb-bell. They are 
occasionally mistaken for the triple phosphates, espe- 
cially when these are small and imperfectly formed. 
When doubt remains acetic acid will prove the condition 
by dissolving the phosphatic crystals, where the oxal- 
ates will remain unaffected. As with phosphaturia, the 
oxalates characterize no special disease, but a certain 
train of symptoms are found present in those who have 
a continued oxaluria. (See works on urinary analysis.) 
Diet plays an important part in the production of these 
crystals and foods known to be rich in oxalic acid should 
be avoided while inflammation of the uriuary tract is 
present. Such are cabbage, spinach, asparagus, toma- 



10 SIMPLE AND SPECIFIC URETHRITIS. 

toes, grapes, and one or two others. Another prolific 
cause of oxaluria is intestinal indigestion, a correction of 
which often quickly causes their disappearance from the 
urine. 

URIC ACID. These crystals are rarely if ever found 
in any but sharply acid urine. Occasionally they are 
seen in freshly passed urine, and it is a common occur- 
rence to find them in urine 10 or more hours after stand- 
ing. They are found sooner in cold than warm weather, 
but unless they appear in from 4 to 6 hours no patho- 
logical significance need be attached to their presence. 
It is these crystals that form in the bottom of vessels, to 
which the laity give the name of brick dust. Gener- 
ally speaking, under the microscope they differ from all 
other crystals in being colored, usually an orange red. It 
is denied by Purdy, but acknowledged by Simon and 
Tyson, that crystals of uric acid at times appear perfectly 
colorless. These latter are not of the star formation, 
but rather rhombic in character. [The author has seen 
them several times, all of which were perfectly colorless.] 
There is no doubt that a urine heavily charged with uric 
acid acts pronouncedly in preventing resolution. There- 
fore it is well when dealing with inflammations of these 
parts to prohibit any and all things known to favor such 
a condition. The same will refer to the amorphous 
variety. The subject is but briefly mentioned in text 
books, but as practically all urinary calculi are composed 
of one or more of the crystals mentioned, the finding of 



THE URINE. 11 

these in the urine, together with symptoms of stone, ren- 
der the diagnosis more positive, and furthermore the 
kind of stone may, with a fair amount of certainty, be 
ascertained. 

CASTS. The pathological significance of, as also the 
formation of urinary casts, is a much disputed question 
even at this late day. The most rational explanation of 
urinary casts, together with their importance is found in 
the conclusions of Dr. Wm. H. Porter (Philadelphia Med- 
ical Journal, April 2d, 1898.) He says : 

1. That serum-albumin as a single proteid substance 
is a thing of the past. 

2. That the epithelium of the uriniferous tubules ex- 
cretes the various forms of proteid substances that are 
found in the urine. 

3. That it is through this excreted proteid material 
that our casts are formed. 

4. That there are two distinct classes of casts, one de- 
noting no structural change in the renal gland, and one 
that does indicate positive retrograde changes. 

5. That we may find casts and no albumin and vice 
versa, and that the former is not infrequent. 

6. That the one class of casts can be found in almost 
every sample of urine submitted to the centrifuge. 

7. That we are enabled by a close and careful study 
of the kind and amount of proteid bodies eliminated 
through the kidney, together with a careful study of the 
size and character of the casts to determine the exact 



12 SIMPLE AND SPECIFIC URETHRITIS. 

condition of the renal glands, and in fact of the system 
at large. 

In cases of true Bright's disease, or where casts are 
found in the urine, even though they be an indication of 
a circulatory change only, much interference will be 
found to rapid and progressive resolution. 

EPITHELIUM. Until recent years it has been a 
much disputed question as to whether it was possible to 
locate the genito-urinary epithelium as coming from any 
one certain portion of the tract. Close observers have 
brought this subject to a point where one can say those 
cells are from a given locality. Carpenter (Buffalo Med. 
Journal April, 1898) says: "Variations in size and shape 
exist, not only between the cells of different parts, but 
between the cells of the same part depending upon the 
condition at that place, the existence or non-existence 
of inflammation, and whether the cells are superficial or 
deelpy seated in the lining membrane. Sufficient 
variations in size and shape can be found to accurately 
determine the previous location of cells as they occur 
in the urine. Many times it is difficult or even impossi- 
ble to definitely locate a lesion from the clinical symp- 
toms in a certain case, and in these cases the informa- 
tion gleaned from a careful observation of the urine, 
particularly the cells occurring in it, is of inestimable 
value." It is possible at times to find epithelium from the 
different parts of the urinary tract in perfectly normal 
urine, but at certain times during inflammatory processes 



THE URINE. 13 

cells are found in large numbers and by shape and con- 
dition showing trouble to exist. I quote the following 
from the article : 

Tubular, i layer. Columnar. 
Henley Loop, Squamous. Not granular. 
Pelvis, i. Battledore. 

2. Round, about twice the size of pus cell. 
Ureter, i . Spindle-shaped, large. 

2. Small, round. 
Neck and Prostate, i. Circular and very refractive. 
Along the urethra, simple columnar until me- 
atus, when they are like prostatic. 
Cells from small renal tubes are always round and 
about half the size of pus corpuscles \ from the large 
tubules they are about half again as large. 
VERY REFRACTIVE. 

i. Fossa navicularis. 

2. Prostate, opposite the sphincter. 

3. Convoluted tubules. 

PUS. Any inflammatory condition of the urinary tract 
will show its existence by the presence of pus in the 
urine which will be rendered opaque, ranging in degree 
according to the amount of trouble present. These cells 
are supposed to be spherical and contain but one nucleus. 
If acetic acid is added to bring this out it may appear as 
one, two, three, or even four distinct spots, yet when a 
high power is used they will be found to be all connect- 
ed, their appearance being due to the different shape in 



14 SIMPLE AND SPECIFIC URETHRITIS. 

which the cell is seen. There is no practical difference 
between pus cells, mucous corpuscles, or leucocytes, and 
either of the latter may be found in the urine at all 
times. Differentiation between these and pus is^ made 
by the number present. In case of the former but very 
few are found even following centrifugalization, where in 
case of pus, the cells are innumerable. It is very neces- 
sary to locate the origin of pus where possible and as an 
aid, symptoms are of great value. In the absence of a 
venereal history, and when no symptoms are present, 
referable to the posterior urethera or bladder, pus in the 
urine may be suspected as having its origin higher up — 
the kidneys. At times it assumes formations which 
aids greatly in locating the origin, thus, if found in 
clumps, (15 to 25 cells) in acid urine and upon standing 
settles to the bottom of the glass in a compact mass, the 
kidney, especially the pelvis, is the seat of trouble. In 
old cases of cystitis the urine is usually alkaline and pus 
is present in great quantities. Visually, pus in the 
urine may be confounded with amorphus phosphates, urates 
mucus, bacteria, epithelium or spermatozoa. Chemical tests 
will to a large extent clear up any doubt, but the micro- 
scope is absolutely necessary for a positive differentiation. 
BLOOD. When blood is found in the urine there is 
some pathological condition present. The appearance 
varies according to the character of the urine in which 
the cells are found, Ordinarily there should be but little 
or no trouble in distinguishing red blood corpuscles from 



THE URINE. 15 

pus or small round epithelium. They appear as bi-con- 
cave discs of a yellowish hue, evenly distributed over the 
field, and when seen in fresh urine their outline is almost 
perfect. When the urine is old they become somewhat 
shriveled, presenting an uneven outline. The origin of 
blood may be located with a fair amount of success by 
visual examination and questioning. Thus, if it appears 
first, precedes the urine, the urethra may be thought of. 
If after the outflow is almost if not completed, it again ap- 
pears and fresh, the posterior urethra or bladder neck, but 
when it is thoroughly mixed with the fluid and of a dark 
brown character, the kidneys is usually its source. Blood 
is occasionally present in acute gonorrhea, when the in- 
flammation is severe. It may then precede the stream. 
Fresh blood appearing after the flow, is indicative of 
acute posterior urethritis, cystitis, venus congestion at 
the internal sphincter, tumors of the bladder, stone, etc. 
When intimately mixed with the urine some grave kidney 
lesion may be suspected. 

MUCUS. Mucus is always found in the urine, yet in 
health there may be so little that it is practically undis- 
cernible without the use of the centrifuge and micro- 
scope. In all catarrhal conditions, especially old cystites 
and pyelitis, mucus is often found in abundance. It 
gives to the urine a syrupy appearance and if disturbed 
after standing will be found to be very ropy. Where 
very little is present it has a tendency, on standing, to 
form in a ball-like condition near the upper surface of 



16 SIMPLE AND SPECIFIC URETHRITIS. 

the urine, but in time it always sinks to the bottom of the 
receptacle. 

SPERMATOZOA. These are occasionally seen in 
perfectly healthy individuals, although in most cases it 
will be possible to obtain a history of a former inflamma- 
tion involving the posterior urethra or that the patient 
had practiced masturbation. It is not an uncommon 
occurrence during gonorrhea to occasionally see the void- 
ed urine contain these in great numbers. This is due to a 
relaxation of the ejaculatory sphincter, allowing them to 
enter the posterior utethra, where they may gravitate 
backwards, intermingling with the urine in the bladder. 
Following coitus the first urine passed generally contains 
spermatozoa, these being washed out from along the 
canal, where they may have adhered. Where sperma- 
tozoa are found only occasionally, especially if there is 
an inflammatory process present, but little attention 
should be paid to them as they will disappear as soon as 
recovery takes place. When a drop appears at the me- 
atus following the urine or defecation, the microscope 
must be used as it maybe pus or prostatic secretion. 

TUBERCLE BACILLI. Even in the presence of 
positive symptoms of tuberculosis of the genito-urinary 
tract, the germ necessary to prove that disease is often 
wanting. When the disease is thought to be present 
examination must not stop with one or two slides; neither 
should one sample of urine be considered sufficient, but 
rather at least a dozen slides should be made of as many 



THE URINE. 17 

different specimens before making any positive state 
ments. The author has known thirty slides to be made, 
each of which was examined very carefully before the 
germs were found. In making examinations the small, 
dark-colored, cheesy masses should be sought for as they 
are the portions most liable to contain the bacteria. 

OTHER BACTERIA. In the absence of inflamma- 
tion of the genito-urinary tract freshly passed urine has 
always been supposed to be sterile, i. e., free from pyo- 
genic bacteria; but such is not a fact, for without genito- 
urinary inflammation such bacteria as the colon or ty- 
phoid bacilli are to be found. At least 40 different 
varieties (Purdy) of bacteria have been found in urine, 
but these must be divided into two classes, those posses- 
sing pyogenic powers the others none. Only the non- 
pyogenic will be considered, these being classed as 
moulds, yeast and fission fungi. 

Molds. These are rare, but if diabetic urine is allow- 
ed to undergo alcoholic fermentation they may usually be 
found upon the surface. 

Yeast. These only develop in acid urine, ceasing to 
multiply as soon as it becomes alkali. They are about 
the size of a red blood corpuscle and are distinguished 
from the latter by irregularity and that they usually occur 
in bead like strings. When yeast is found sugar is gen- 
erally present. 

Fission Fungi. This variety is usually present in any 
urine having a tendency to undergo putrefactive changes. 



18 SIMPLE AND SPECIFIC URETHRITIS. 

They appear under the microscope in chain-like forma- 
tion, rod-shaped, long spirals, or as cocci. With a half 
inch objective these bacteria can be seen in active mo- 
tion. At times they may be found in freshly passed 
samples, and unless chloroform or some similar drug is 
added will always develop in urine if allowed to stand 
for some time. They give to the urine a modified ground 
glass appearance, will not settle to the bottom on 
standing and the fluid cannot be rendered clear by use 
of the centrifuge. They are found quite commonly in 
the female, also in cases where there is urethral obstruc- 
tion, catheter sounds, etc., having been used. 

MUCOUS CYLINDERS. (See works on the urine.) 



CHAPTER III. 

SIMPLE URETHRITIS. 

SYNONYMS. Non-virulent, non-specific. 

Definition. An inflammation of the urethra due to bac- 
teria other than the GONOCOCCI. 

Causes : 
Predisposing, Irritation due to : Substances in the urine ; 
Substances from without ; Excess in venery, or 
Alcoholics, and Psychical. 
Exciting : Bacteria, derived from either internal or ex- 
ternal sources. 
In 1876 Noeggrath made the statement that 80 per 
cent, of males had gonorrhea, that 90 per cent, of these 
were never cured and could infect. This statement is 
true in a large measure, still, as he acknowledges later, 
it was a great deal too strong. Without hesitancy it 
may be safely stated that although the healthy urethra 
can become inflamed by germs other than the gono- 
cocci, in about 90 per cent, of the cases of what are 
proven to be a simple inflammation there existed a pre- 
vious involvement, and this was of a gonorrheal nature. 
It is possible that only a small granular spot was pre- 
sent or the normal calibre of the canal was impinged 
upon to an unmeasurable degree, yet both conditions 
would be capable of producing a loss of resisting power 
in the surrounding tissue. Furthermore, with the above 



20 SIMPLE AND SPECIFIC URETHRITIS. 

there is always a more or less inflammatory condition 
present, yet there may be no pyogenic cocci excepting 
the strepto or staphylococci. With such a condition it 
can be readily understood how excessive coitus, traum- 
atism from operation, the rough usage of sounds, etc., 
might light up the old foci and cause a general inflam- 
mation of the whole canal. 

It is yet impossible to say where congestion ends and 
inflammation begins, but one thing is evident for the 
production of the latter there must be pyogenic bacteria 
present. One other factor is necessary for the produc- 
tion of inflammation, a lowered vitality of the tissues, 
and this is just the condition produced by congestion. 
It is thus evident how the condition known as lithemia 
can not only make a rich soil for germ cultivation, but 
furthermore can, and does, aid greatly in prolonging in- 
flammations (involving the urinary tract) due to gonococ- 
ci or other bacteria. As regarding the bacteria found in 
the urine and capable of producing inflammation, the 
colon bacilli are the most important. Hall says : " Found 
normally in the intestinal canal and ordinarily about the 
foreskin, vulva and neighboring parts, it is occasionally 
found in the normal anterior urethra. It is usually 
harmless when found in these localities, but is extremely 
pathogenic in many cases if transmitted elsewhere." 
The colon bacilli can and often do cause many diseases 
as cystitis, nephritis, pyleonephritis and inflammations 
of various other portions of the body. Further, Hall 



SIMPLE URETHRITIS. 21 

says: " It is well known that cystitis is often caused by 
the introduction of the organism upon the catheter from 
the outer orfice of the urethra." If these statements 
can be accepted as facts, and various experiments have 
been made that positively prove that they are capable of 
producing inflammation in a bladder previously congest- 
ed to an extreme degree, what is to prevent the same 
organism from causing urethritis?. I am positive that in 
a case seen by me not long ago, the inflammatory con- 
dition was due to the colon bacilli, the remote cause being 
the presence of urethral polypi which had become irri- 
tated, due to excessive coitus, plus a urine for some rea- 
son loaded with phosphatic crystals. By careful 
examination, finding no gonncocci, the woman was sent 
to me for a like examination. There was no evidence 
of gonorrhea, and furthermore positively no gonococci, 
although many slides were examined. In the man the 
colon bacilli were numerous. I think the case was 
proven to be correctly diagnosed for the reason that, 
after removal of the polypi and restoration of the urethra 
to a normal condition, the man in question had sexual 
intercourse with the woman, and although often repeated 
no return of the trouble has manifested itself. In a 
paper by Dr. J. Clifton Edgar, 1899, he has given the 
results of careful examinations of the vulva of pregnant 
women and says : "Of 30 cases examined the staphylo- 
cocci was found 8 times; s. aureus 3 times, streptococcus 
once ; negative or sterile, 19 cases, coli communis was 



22 SIMPLE AND SPECIFIC URETHRITIS. 

not found." Although this deals entirely with preg- 
nant women the same, or possibly worse, state of affairs 
could be found in the non-pregnant. As these bacteria 
have known pyogenic power it may be stated conclusive- 
ly that in a previously healthy urethra which has been 
congested for a time, due to oxalates, urates, alcohol or 
excess in venery, inflammation may take place, the gono- 
cocci in no way taking part as a causative agent, but 
rather one of the enumerated being the offending germ. 
These bacilli may be the only germs present, but more 
often there are other pyogenic bacteria demonstrable 
with the microscope, and in these cases careful question- 
ing will bring out the fact that at some time there had 
been a previous specific (gonorrheal) involvement. It 
should be thoroughly understood that the condition 
known as lithemia cannot cause inflammation, per se, 
but they (the salts in the urine) can and do cause more 
or less congestion, and the colon bacilli or other pyogenic 
cocci either taken from the vulva or by migration from 
the rectum, anterior urethra, or by way of the kidneys, 
produces the inflammation. There seems to be no doubt 
that certain irritant chemicals when introduced into the 
healthy urethra are at times followed by inflammation. 
What bacteria are the causative agent in every case is as 
yet undecided, but one thing is sure, the colon bacilli 
have been found. Whether they were in the canal or 
gained entrance from the meatus is a question, but one 
case, the patient never having gonorrhea, in fact never 



SIMPLE URETHRITIS. 23 

having had sexual intercourse, following an injection of 
nitrate of silver (the reason for which I could not ascer- 
tain) caused a typical urethritis, careful examination 
failing to show bacteria other than the colon bacilli and 
a few germs known to inhabit the urethra normally. (See 
plate No. I, showing these.) 

There is little doubt that urethritis can be produced 
by the introduction of unclean instruments, but as in- 
strumentation is generally called for in some condition 
caused by a gonorrhea, and for the treatment of a canal 
in which there exists a lesion, it is clearly evident that 
there were pyogenic bacteria present and due to rough 
handling, plus an unclean instrument, the old localized 
spot was irritated and possibly infected sufficiently to 
cause extension involving the entire membrane. It is 
possible for the bacilli already described as being found 
around the glans to gain entrance into the urethra and 
cause an inflammation. In the case of the polypi already 
alluded to, I think this was the mode of invasion, for, of 
the three small tumors present, the first was located al- 
most at the junction of the urethera with the glans. 
Visual inspection of the part showed intense inflamma- 
ion of this and the sourrounding tissue. Alcohol or 
excesses in venery only act as a predisposing cause 
in a healthy urethra, but where there are old localized 
inflammatory spots, either of the above abuses can so 
irritate them that a general inflammatory condition is 
produced, no gonococci being found. 



24 SIMPLE AND SPECIFIC URETHRITIS. 

There is no doubt that a urethritis can be produced by 
worry and I have seen such a case which tallied in every 
way with a gonorrheal infection, excepting the presence 
of the bacteria necessary to call it by that name. Al- 
though no gonococci may be found after careful search 
in every case of this description, it will be possible to 
obtain a history of former specific inflammation and the 
urine will show that there are localized spots of inflam- 
mation if not of stricture formation. In these cases the 
patient is generally a married man and the intercourse 
illicit. The constant worry that he undergoes, thinking 
of possible venerial infection, accompanied as it is daily 
with stripping to find a discharge sooner [in my case 
eight days] or later owing to the phosphaturia which 
causes pronounced congestion, irritates the old spots, to 
an extent that an acute inflammatory condition is estab- 
lished. Urethritis at times follows instrumentation, 
especially cutting operations in the urethra, but it is safe 
in every case to conclude, that although there is an in- 
flammation present containing no gonococci, these germs 
have been present at some time and have left telltale 
marks of their former presence in the shape of sub- 
mucous spots harboring bacteria capable of being revived 
and producing trouble, accompanied by symptoms slight- 
ly less severe, but resembling in every way those due to 
specific urethritis. 

As to the infectiousness of this form of urethritis, the 
description of the same occurring in chronic specific ure- 



SIMPLE URETHRITIS. 25 

thritis will amply suffice. [See infectiousness of chronic 
specific urethritis.] 

Although the microscope is a very valuable instrument 
for arriving at the true condition in the male, in the fe- 
male it will fail in most every case to show the gcnococci, 
even though the patient may be suffering from anicute 
infection. That this is a positive fact, the author has 
proven time and time again. As an explanation of this 
it maybe stated that in at least 50 per cent, of the cases 
the infection takes place at the cervix, and as referred to 
further on, the vagina being inhabited by bacteria which 
seem to be of a canabalistic natnre, gonococci that find 
their way into this tube are immediately destroyed. 
Therefore symptoms, such, as eroded cervix, swollen 
cervical crypts, free and prolonged menstruation with 
ovarian or tubular involvement is in the great majority 
of cases more positive than the microscope. 

The opinion cannot be expressed too forcibly that 
there was never a specific inflammation (gonorrheal) 
produced in a healthy male (even though there may have 
been a former inflammation, but this entirely cured) ure- 
thra by secretion from the vagina, either menstrual or 
leucorrheal, where a careful examination, visually, digi- 
tally and microscopically, did not show evidences of 
gonorrheal infection being present at some time; 



EXPLANATION, PLATE I. 

Normal urethral cocci and bacteria, the former resem- 
bling the staphylococci, the latter the Tubercle,Typhoid 
and Bacillus coli communis. 

Mucus. Pus« Epithelium, caudate and round. 

26 




The accompanying plate is an exact 
reproduction from a case of the author's 
with the camera tucida, Spencer 1-1 2th oil 
emersion lens and methylene blue as the stain. 



PLATE I. 




CHAPTER IV. 

SIMPLE URETHRITIS. 

SYMPTOMS, DIAGNOSIS AND TREATMENT. 

SYMPTOMS. These are similar in every way to 
acute gonorrheal infection, only of a much milder type. 
The first appreciable symptom, an itching or crawling 
sensation, is described as being somewhere along the 
canal unless the infection has taken place at the meatus, 
as in the case already cited (papilloma). Incubation 
varies and may be from one to ten, or even fifteen days. 
The discharge, at first muco-purulent, becomes purulent 
less rapidly than in acute gonorrhea, and it is rare to 
find the characteristic hue so common in gon 
cases. The urine is almost characteristic as a diagnos- 
tic point. When the case is seen early (within 48 hours) 
if the condition is due in any way to irritation of a pre- 
vious inflammation (submucous inflammatory spots fol- 
lowing gonorrhea) the urine, instead of being opaque to 
a more or less degree, is only very slightly turpid, and in 
the fluid will be found shreds and debris characteristic 
of some old inflammatory trouble. The inflammatory 
reaction is less severe than in specific urethritis, it be- 
ing quite uncommon to find chordee, even where no 
measures have been used for its prevention. Invasion 
of the posterior urethra is slow and at times patients 
will not complain of frequency of urination throughout 



30 SIMPLE AND SPECIFIC URETHRITIS. 

the case, although the urine, viewed in two glasses, will 
show but very little if any involvment of that region. I 
have never seen epididymitis accompany the condition, 
but still this complication might arise at any time. 
Ardorurinae is present, but only to a degree where ques- 
tioning of the patient will bring out the fact. It must 
be understood that although this simple inflammatory 
condition is much milder than a true gonorrhea, at times 
and especially if irritated, the condition assumes great 
virulence as the following will show: X. Y. aged 27. M 
Acute gonorrhea first and only time, Sept., 1890. Dis- 
charge continued for a long time, finally stopping entire- 
ly. In 1894 the patient called complaining of slight fre- 
quency of urination, dribbling and other symptoms lead- 
ing one to think of stricture. Examination of the urine, 
also the canal, showed such a- condition to be present and 
located immediately in front of the compressor muscle. 
This was dilated to normal and the patient instructed to 
call every six to ten months for examination and the pas- 
sage of a sound, if necessary. He did not return for two 
years at which time the stricture was found considerably 
contracted. It was again dilated to normal, but he again 
neglected it as before not returning until some time in 
1900 when the following condition was found to be pres- 
ent: slight discharge, urine clear, excepting shreds, no 
ardorurinae and positively no gonococci. For some time 
he had been using a condom for the prevention of infec- 
tion. The condition was explained and appropriate 



SIMPLE URETHRITIS. 31 

instructions given. The discharge began to let up on 
the fourth day, he practised intercourse, assuming it 
was not a case of gonorrhea and that this would do 
no damage. On about the third day after this the most, 
aggravating symptoms appeared, such as urination every 
twenty minutes, severe pain following the act, with blood 
and temperature ranging at ioo to 103 F. Examination 
showed an acute double vesiculitis, also a large and 
tender prostate, the urine being loaded with pus and al- 
bumin. 

DIAGNOSIS. There is but one absolutely positive 
way of differentiating between specific and non-specific 
or simple urethritis, viz., the microscope. Although this 
instrument is one of the greatest helps in medical diag- 
nosis, to use it with any degree of correctness much 
practice and a fair acquaintance with the various bacte- 
ria (especially those found in this region) is absolutely 
necessary. Inhabiting the normal urethra and around 
the meatus are found bacteria resembling the tubercle 
and colon bacilli and from this latter the former must be 
differentiated. Undoubtedly the pus cocci are often 
mistaken for the gonococci, at times resembling the lat- 
ter, being found in pairs, intracellular or at least in close 
proximity to the pus nucli, having lost their character- 
istic grouping through spreading, etc. The pseudo gono- 
cocci of Lustgarten most resemble the gonococci and 
great care must be exercised in differentiating between 
them. In view of the above it is safe to say that unless 



32 SIMPLE AND SPECIFIC URETHRITIS. 

one is very familiar with the microscope and bacteriology 
the safest method of differentiation is dependence upon 
symptoms. (Where evidence may be called for in a 
crimnal case or divorce may be the result of an opinion, 
it is always best to refer these to seme one skilled in bac- 
teriology thus saving yourself much annoyance and cha- 
grin should the case come to trial.) As previously referred 
to, the urine is the most important point in diagnosis and 
great care should be used in examining the same both vis- 
ually and microscopically. In acute gonorrhea, and even 
exacerbations of a condition not too old, the urine takes 
on an opacity that becomes more pronounced as the 
inflammation progresses, showing marked involvment of 
the whole membrane, no shreds or debris being seen. 
On the other hand, in a condition of urethritis develop- 
ing from an old spot of dilated and inflamed membrane 
the urine may be opaque tQ a more or less degree, but 
floating in the liquid will be found shreds and debris. 
Even though the condition may develop in a canal which 
has never been inflamed before the urine rarely takes 
on the degree of opacity as seen in acute gonorrhea. 
The history of the case is valuable, for if, as is seen oc- 
casionally, inflammation developes in the urethra of a 
person known positively to be in a condition preventing 
coitus or the same arises following an operation where 
the patient has been continent for weeks we can have 
little hesitancy in assuming that a non-specific inflam- 
matory infection is present. 



SIMPLE URETHRITIS. 33 

TREATMENT. Pathologically there is no difference 
between a simple and specific urethritis, excepting with 
the latter variety the gonococcus is present, where in 
case of the former there is generally some previous pa- . 
thological condition which usually acts as a predispos- 
ing cause and must be removed before a cure is com- 
plete. The symptoms being of a mild type internal 
medication is rarely called for, but general hygienic and 
dietary measures must be carried out as closely as 
though the case was one of gonorrhea. In all cases it 

FIG. I. 




is absolutely necessary to first remove the general in- 
flammatory condition of the membrane, this being best 
done by very weak antiseptic astringents, as the author's 
tablet for the treatment of the first stage of acute gon- 
orrhea. * 

f& Hydrarg. Chlor. Cor., gr. ^ 

Pot. Permang., gr. % 

M. Dissolve in 5 oz. of hot water. 

Sig. Use six or seven syringefulls a.m. and p. m. 

*For urethral injections by the patient no syringe should ever be advised 
excepting one with a blunt point, as shown in Fig. 1. It can be made of hard 
rubber, all glass or glass with a soft rubber tip. 



34 SIMPLE AND SPECIFIC URETHRITIS. 

If the use of the above for a week or ten days is suf- 
ficient to clear the urine the cause should be immediately 
sought for and removed where possible. In some cases 
where the inflammation is marked it may be necessary 
to follow the above by the use of a purely astringent 
solution and in strength sufficient to overcome the in- 
flammation. For this possibly the best is the zinc 
sulph. sol. (See chronic specific urethritis.) As has 
already been stated, the predisposing cause of these 
conditions in the majority of. cases is due to some result 
of a gonorrhea, and this is evidenced in the urine. 
Stricture, chronic inflammatory spots and follicular in- 
volvment is characterized by epithelial desquamation. 
Finding such, the canal must be searched either by 
bulbous bougie, or by aid of the electric light. Any of 
these conditions being found they must be treated ac- 
cording as described for the same occurring in chronic 
specific involvement. Polypi must be removed, using 
antiseptic precautions. It is scarcely necessary to men- 
tion the fact that the canal should be put in a normal 
condition, and when this is accomplished excess in 
venery, alcoholics, or a urine loaded with salts of any 
kind, will never produce a relapse. (See treatment of 
chronic inflammation of the urethra.) There is one 
class of cases where it is not necessary to await the 
action of astringents or antiseptics, viz : Psychicial. In 
this condition the urine is usually perfectly clear to the 
naked eye, excepting for the presence of one or several 



SIMPLE URETHRITIS. 35 

shreds, these indicating urethral contraction behind which 
the canal is in a dilated and chronically inflamed condi- 
tion. After thorough flushing with Formaldehyde, care- 
ful exploration will usually detect some obstruction, 
even though it be but one number [French] below the 
normal. When the contraction or inflamed spot is posi- 
tively located the canal should be dilated at once (using 
judgment as to amount), after which the whole mem- 
brane should be flushed with a i -14000 sol. of silver. 
[Never use anything but distilled water.] In nearly 
every case all trouble stops at once. The dilatation 
should be repeated at intervals of a week until the urine 
shows the absence of shreds and pus, this indicating 
that the membrane is in normal condition. 

It is rarely necessary to give medicine internally for 
this condition. Where there is a marked oxaluria or 
uric acid is in great excess, these conditions should be 
remedied. Balsams or other stimulating diuretics tend 
only to cause stomach derangement, with possible low- 
ering of the patient's vitality, and for that reason cannot 
be advised. When the condition assumes a type of 
severity, as shown in the case reported, the patient must 
be put to bed immediately, all local medication stopped, 
controlling the symptoms by opiates until the acute in- 
flammatory condition has entirely subsided, when the 
case should be treated according to the methods advised 
for chronic specific urethritis. (See treatment of that 
disease.) 



36 SIMPLE AND SPECIFIC URETHRITIS. 

SUMMARY. 

i. The term Simple Urethritis, called so to different- 
iate it from an inflammation of the urethra where speci- 
fic (gonococci) germs are present, is a misnomer and 
should be changed as it is misleading to the inexperi- 
enced. It must be acknowledged if both are treated 
with the same amount of precaution the non-specific va- 
riety yields more rapidly and resolution is established 
sooner, but knowing that it is not of a gonorrheal nature 
often makes both physician and patient careless and the 
result may be far worse than if a true specific infection 
was present. 

2. Excepting in case of a most positive history of 
non-infection, expertness in the use of the microscope or 
where a medico-legal case is in question, all urethrites 
should be considered as specific. 

3. Diatetic and hygienic instructions must be advised 
and carried out as carefully as though the disease was of 
a specific nature. 

4. A simple urethritis is infectious, i. e., may cause an 
inflammation in the opposite sex through the presence of 
strepto. or staphylococci. 

5. There is always a predisposing cause which must 
be removed, otherwise the result will be a return of the 
trouble. 



CHAPTER V. 

CHRONIC SPECIFIC URETHRITIS 

SYNONYMS. Chronic gonorrhea, gleet, chronic clap, 
and chronic urethritis. 

Definition. A chronic inflammation of the urethra, fol- 
lowing an acute condition, the latter being due to gono- 
cocci. 

Various are the opinions as to when an acute specific 
urethral inflammation assumes a chronic condition, i. e., 
when progressive resolution from the acute or subacute 
stage ceases and the membrane takes on a chronicity, 
the duration of which at times is prolonged for years. 
Otis once said : "Any case of urethral inflammation that 
subsided inside of six weeks is not a gonorrhea." To- 
day we know this statement to be erroneous, for al- 
though the large number of ten to fourteen day cures 
may be questioned, still it is the good luck of every sur- 
geon to occasionally see a perfect result in three weeks. 
Much must be taken into consideration before attempt- 
ing to fix a definite time when one can say this is a 
chronic condition I am to deal with. Many complica- 
tions may arise during the acute or subacute condition 
which may prolong the inflammation, but after their sub- 
sidence and active treatment is again resumed the case 
goes on to complete recovery. Such conditions may be 



38 SIMPLE AND SPECIFIC URETHRITIS. 

mentioned as epididymitis or epididymo-orchitis, severe 
chordee, edema, producing phimosis or periphimosis, 
with accompanying balanitis. (There is no doubt but 
that the medicinal treatment used by some physicians 
add greatly in prolonging the acute condition and in this 
way postponing a chronicity.) Other facts must be taken 
into consideration before an unqualified answer is admis- 
sable. A complete cure of gonorrhea occurs, not when 
there is no visible discharge, but when there is no dis- 
charge and the. morning urine is free of all urethral des- 
quamination, (shreds and chunks of pus.) This may 
suffice in the majority of cases, but we do find those 
where the above conditions may be present, but if the 
semen or prostatic fluid be examined it will show that 
a latent inflammatory action is present and that there is 
germs, gonococci, which are capable not only of produc- 
ing inflammation in the female, but of infecting a healthy 
anterior urethra in the individual. It does not mean 
that the urine must be transparent, for turbidity may be 
marked, but evidences of localized or general inflamma- 
tion should be absent. Morning urine may be turbid 
from various causes, such as phosphates, mucus due to 
extreme congestion along the urinary tract, or, as 
occasionally occurs, the semen may find its way into the 
posterior urethra and become thoroughly mixed with the 
urine in the bladder, rendering both portions of the 
glass test opaque. Viewing the treatment of acute 
gonorrhea from a most rational standpoint and with no 



CHRONIC SPECIFIC URETHRITIS. 39 

serious complications intervening, it is safe to say that 

A URETHRAL INFLAMMATION EXTENDING OVER EIGHT 
WEEKS HAS REACHED A STAGE WHERE RESOLUTION HAS 
BEEN CHECKED AND CHRONICITY IS ESTABLISHED. The 

causes of continued urethritis are many, and though 
some may be considered trivial, they are at times very 
important in continuing inflammation. 

Too much attention cannot be given to a careful ex- 
amination of the urine in every case (see chaps, i and 2) 
for here may be found one and the most important fac- 
tor as a causative agent. It must be remembered that 
although gonococci are the cause of the large majority 
of urethral inflammations, still the urethra can and does 
become inflamed from other causes, and this inflamma- 
tion may be continued indefinitely. Although this con- 
dition will be dealt with more fully later on, a word of 
explanation here may be of value. As an example of 
such a condition a case may be assumed. The indi- 
vidual contracts a gonorrhea, which after possibly 
months of injection and manipulation ceases to flow, but 
there remains trouble in the urethra which in time will 
become localized at one or more spots in the form of a 
chronic inflammation involving the deeper tissues and 
resulting in but one thing, stricture. It is well known 
that as soon as contraction takes place there is an ob- 
struction to the free and normal flow of urine and but 
one thing follows, dilatation of the canal behind the ob- 
struction. A condition of chronicity existed already, 



40 SIMPLE AND SPECIFIC URETHRITIS. 

and now the irritation produced in the obstructed pas- 
sage tends to increase the trouble and the thin mem- 
brane becomes inflamed throughout its entire thickness. 
This is well demonstrated if the small shreds or debris 
be examined microscopically for they will be found to 
consist of pus cells, degenerated epithelium and numer 
ous cocci. These cocci need not necessarily be specific 
(gonococci) but strepto. and staphylococci are found in 
great numbers. As a result of such a condition we often 
see that after a night's debauch in which sexual inter- 
course has been practiced freely, the next or subsequent 
morning a slight moisture, and even a drop, may be 
brought forward to the meatus. The woman is at once 
accused of giving infection, when in reality the excesses 
partaken of has simply intensified the old condition to 
an extent that pus is produced in macroscopical quanti- 
ties. This one thing is the main reason for patients 
telling you they have had a gonorrhea ten or twelve 
times. The condition is the result of a chronic inflam- 
mation of the urethra, and had the membrane been put 
in a normal condition at first infection no return would 
have manifested itself. Cases of this description must 
be regarded as chronic urethritis, but unless the physi- 
cian can demonstrate such to be a fact (by aid of a mic- 
roscope) the patient, to avoid serious complications, 
should be treated as though infected with an acute 
gonorrhea. 



CHAPTER VI. 

CHRONIC SPECIFIC URETHRITIS 

CAUSES. 

The causes of chronic urethritis are many, and although 
at times some trivial condition may be thought not to be 
of much account in continuing the trouble, this slight 
discrepancy may be the sole and only preventative of 
resolution. These may be classified under various head- 
ings, and as far as possible in order of their frequency : 

i . Early and persistent interference. 

2. Thickening of the membrane, localized inflamma- 
tory areas. 

3. Granulations. 

4. Stricture. 

5. Contraction of the navicular valve and small 
meatus. 

6. Anemia. 

7. Constitutional conditions. 

8. Lithemia. 

9. Prostatic or vesicular involvement. 

10. Folliculitis. 

11. Idiosyncrasy. 

12. Want of tone in the tissues. 

EARLY AND PERSISTENT INTERFERENCE. 

There is no doubt that early and persistent interfer- 



42 SIMPLE AND SPECIFIC URETHRITIS. 

ence is the most important factor in prolonging urethral 
inflammation. This statement, although radical, is 
made without fear of contradiction. Case after case of 
this description, extending over a period of months, has 
been quickly and permanently cured by stopping all in- 
strumental or other local [office] measures, giving the 
patiant a rest for two or three weeks, and then for a few 
days treating him in a rational manner. That the above 
statement is not theory should be evident to all my read- 
ers after trial. We are dealing with an inflamed mem- 
brane, said to be more delicate than the conjunctiva, yet 
what treatment does it get? Constantly irritated, day in 
and day out, and this by sounds, for it is a fact that cer- 
tain authors advise the passage of such instruments daily 
for the cure of a chronic urethritis. Not this alone can 
be considered as the only cause of irritation, for irriga- 
tions and deep injections are used that will cause trouble 
in a perfectly healthy membrane. It is not denied that 
not only the sound but medication with the same drugs 
may be and generally is necessary in almost every case, 
but the time at which they should be used and the 
strength of the solution is the important point. Invari- 
ably it is the rule, if discharge does not entirely disap- 
pear in four or five weeks, that sounds are at once brought 
into play, and as a result thereof the trouble is continued. 
Even from an internal view, measures are being used 
which can and do act as an irritation, not necessarily 
from any effect produced upon the urine, but by the con- 



CHRONIC SPECIFIC URETHRITIS. 43 

tinued administration of copabia and other drugs thought 
to be specifics the patient's stomach is put in a condi- 
tion whereby mal-assimilation is produced and food is 
of no value to the partaker thereof. In other words, by 
interference with normal assimilation the tissues of the 
patient become relaxed, resisting power is wanting, and 
the membranes cannot in any way assist in the work 
they should perform. 

THICKENED MEMBRANE. 

This is a condition that is present in every case of 
acute gonorrhea, and when resolution is perfect this 
thickening entirely disappears ; but perfect resolution 
from an acute gonorrheal inflammation is a result that 
occurs only in a small percentage of cases. The thick- 
ening may be located anywhere in the canal, but usually 
it is found in the deeper, more vascular and dependent 
portion up to two inches in front of the compressor. It 
is known that the slightest deviation from the normal (in 
any part of the body) will surely be accompanied by 
some trouble, and in the urethra it manifests itself in 
the shape of irritation to an already irritated or inflamed 
spot. The resillt of such a condition is obvious, and 
but one thing occurs, exhuberant granulations or increas- 
ed thickening, with more urinary obstruction, and this, 
followed by dilatation of the canal behind, an extension 
of the inflammation from the thickened portion, both 
anterior and posterior thereto, such resulting in the for- 



44 SIMPLE AND SPECIFIC URETHRITIS. 

mation of pus which can be seen at the meatus. This 
is the condition that writers formerly laid much stress 
on, denominating the same stricture of a large calibre. 
As granted, such a condition acts as an obstruction to 
the free passage of urine, but as there is no cicatritial 
tissue present and in all probability no new tissue formed 
in these conditions it cannot be considered stricture, as we 
regard such a formation. Instead of removing as much 
of the surrounding inflammatory trouble as possible be- 
fore trying to eradicate the cause, the reverse is attempt- 
ed, the cause is sought for and its removal tried at 
once. There is but one result, the thickening may be to 
a certain extent squeezed out, but at the same time the 
surrounding inflamed tissue is irritated to a degree that 
simply prolongs the trouble. 

GRANULATIONS. 

As already stated, these spring from an area of in- 
flammatory thickening and it is safe to assume that their 
presence is dua to irritants, let these be sounds, irriga- 
tions, injections or powders applied locally. If the sur- 
rounding membrane is in a fairly normal condition the 
"secretion from this is not very copious, being merely 
enough to cause a glueing of the meatus which, if open- 
ed, allows a small pin-head drop to be brought into view. 
Of course if they involve the membrane to any extent 
the discharge may be markedly free. 



CHRONIC SPECIFIC URETHRITIS. 45 

STRICTURE. 

As alluded to elsewhere true stricture as a complicat- 
ing factor must not be thought of during the first infec- 
tion, unless the case has extended over many months or 
there is a history of injury to the parts, and then not 
unless the urine shows positive evidence that such a 
condition may be present. The earliest development of 
well marked stricture seen by the author and following 
gonorrhea, with no history of traumatism, was one year. 
The patient was seen with Dr. Robt. Taylor in Bellevieu 
hospital in 1895. Even here the veracity of the patient's 
statements was much in question. As admitted, thick- 
ened membrane, granulations, or a well developed nav- 
icular valve will, to a certain extent, offer an obstruction 
to the free flow of urine, but none of these conditions 
can be considered as true stricture. The urine is the 
most valuable aid in the diagnosis, without the use of 
the searcher, and as in this condition there is always 
more or less pus present such an instrument, except 
under certain well defined conditions, should not be 
used until the urine shows by its clearness (except pos- 
sibly shreds) that all general inflammation is removed 
and only the local condition remains. Shreds indicating 
urethral contraction must not be confounded with a 
similar appearance found in all samples of urine accom- 
panying progressive resolution from an acute or recent 
chronic inflammation, for in the latter case they gener- 
ally disappear as the membrane clears up, where on the 



46 SIMPLE AND SPECIFIC URETHRITIS. 

other hand they are characteristic of obstruction (stric- 
ture or marked thickening of the membrane) the urine 
may be perfectly free of pus, but one or two shreds will 
remain until the canal is dilated to its normal calibre. 
These shreds, when indicative of contraction, are well 
formed, looking much like pieces of thread, one-half to 
three-quarters of an inch long. When these characterize 
localized inflammatory areas they are illy defined, being 
ragged and uneven, resembling a piece of string with a 
knot or two tied in it. It has been stated heretofore 
that trouble exists until the urine is entirely clear ; 
therefore if shreds are present after the urine is free 
from all visible pus, discharge or no, the canal should be 
searched for stricture or other obstruction. The rule that 
no instrumentation should be attempted until the urine 
is clear must be adhered to, yet occasionally a case is 
met where after most careful treatment both specimens 
appear similar, excepting, possibly the first which may 
contain well marked shreds (tripperfaderi). Such a con- 
dition is usually due to stricture, behind which the mem- 
brane is in a state of chronic inflammation and seeming 
to insist on remaining so until the cause is removed. 
In searching for urethral stricture nothing but a bulbous 
instrument should be used, those made of silk being 
much preferable as they more readily follow the urethral 
curves. A urethromometer is a very unsatisfactory in- 
strument, and as a New York surgeon once said to the 
author, ''with one of those instruments a stricture can 



CHRONIC SPECIFIC URETHRITIS. 47 

be found in any urethra/' Either a well developed na- 
vicular valve or the compressor muscle will catch and 
hold the searcher, yet neither of these structures should 
be considered a stricture, for although the former may 
to a certain extent obstruct the free flow of the urine it 
is a normal anatomical structure and is present in every 
male. As at least sixty seven per cent, of strictures are 
situated in the deep urethra, and at times immediately in 
front of the aforementioned muscle, the searcher should 
be made to enter the posterior urethra, this being evi- 
denced by the sensation of urination which the patient 
experiences the moment it passes this muscle. The 
fact must not be forgotten that accompanying all cases 
of stricture there is more or less pus found in the urine. 
The amount and source of this product of inflammatory 
action depends entirely upon the age of the contraction. 
In any and all conditions the inflammation is more mark- 
ed in close apposition either in front or behind the strict- 
ured portion of the canal. In cases of long standing, 
especially if the patient's vitality has become impaired by 
long continued suppuration the trouble extends back 
wards and upwards involving the prostate, ureters and 
kidneys. The urethra being involved it must be consid- 
ered a chronic urethritis, and as stated heretofore excess 
in alcoholics, coitus, etc., often aggravates the condition 
to '[ the extent of producing a subacute inflammation at 
times diagnosed as a fresh infection. 



CHAPTER VII. 

CHRONIC SPECIFIC URETHRITIS 

CAUSES (CONTINUED.) 

CONTRACTION OF THE NAVICULAR VALVE. 

A well developed valve or a very small undilatable 
meatus will act exactly like a stricture and continue the 
trouble indefinitely unless relieved. There can be but 
little doubt that the valve which was well developed be- 
fore inflammation had attacked the canal was by the 
use, or rather abuse, it received from syringe points (see 
fig. I ), plus the inflammation, hypertrophied so to speak, 
that in the fourth week it is found to be acting as a de- 
cided obstruction. The urine which is usually highly 
acid meets the obstruction and is thrown backwards, the 
dilatation caused there, together with the friction pro- 
duced, keeping up a state of chronic inflammation. 

ANEMIA. 

This condition, when well developed, is undoubtedly 
a prolific cause of continuing the trouble. The causes 
are various, but barring those that may be present from 
a constitutional condition, it is usually found that the 
anemia is due to the heroic administration of capabia or 
other drugs that have deranged the stomach and intest- 



CHRONIC SPECIFIC URETHRITIS. 49 

inal tract to an extent that assimilation is seriously in- 
terfered with. Another and the most important cause 
of acquired anemia is the long continued and profuse 
suppuration which the patient has undergone. 

CONSTITUTIONAL CONDITIONS. 

As referred to above, this may be the sole cause of 
the anemic condition, in fact the condition of anemia 
may have been present before the patient contracted the 
inflammatory trouble, A constitutional cacexia not only 
being one of the most important causes of continued in- 
flammation is as bad as the inflammation itself. 
This does not necessarily mean that cancer, Bright's or 
tuberculosis are not bad conditions of affairs unless 
accompanied by urethral inflammation, but I do con- 
tend that latent genito-urinary tubercular foci may 
be revived and set into activity by the acquirement 
of inflammations along the urinary tract. This has 
been well proven to me in two or three cases. In 
one, a man aged 45 whose immediate family had all 
died of tuberculosis never exhibited a symptom of the 
disease until he contracted a gonorrhea which extended 
over a period of two years or more before there was a 
secession of the discharge. About this time he noticed 
that he was getting up at night to urinate and the urine 
was slightly opaque. The prostate was accused of the 
trouble and appropriate measures used, all of which 
proved of no avail. The urine was carefully examined 



50 SIMLPE AND SPECIFIC URETHRITIS. 

but at the time no evidences of renal involvement was 
apparent, the trouble seeming to be located exclusively 
in the posterior urethra and prostate. A perineal sec- 
tion was done with bladder drainage for ten days, at 
the same time stretching the gland to 45 F. Very little 
improvement followed this and repeated urinary exam- 
inations were made. Finally, after much trouble (see 
examination for tubercle bacilli) the bacilli of tuberculosis 
were found and also evidence of pelvic involvement. 
The patient was put upon valerinate of creosote and a 
change of climate advised. Almost immediately there 
was improvement and although the patient is living, had 
he continued to reside in a favorable climate, his condi- 
tion might be much better than it is at present. The 
other two cases were of a similar nature and should go a 
long way towards proving the fact that undoubtedly there 
were tubercle bacilli in the body and all that was neces- 
sary for their revivement into action was a continued in- 
flammation which would lower vitality at the same time 
producing a soil upon which they could grow and thrive. 
Cancer, Bright' s disease and diabetes are very important 
as causative agents. Syphilis, when present, although it 
may not manifest itself externally, exerts a marked in- 
fluence, at times, in the prolongation of the existing con- 
dition. Especially is this true if there is present what 
is termed a cacexia, or rather external evidences that the 
patient is suffering from some constitutional disease which 
is known to be SYPHILIS. To me this disease as a 



CHRONIC SPECIBIC URETHRITIS. 51 

causative agent has a standing in the front rank, and in 
two cases (females) of genital inflammation although hero- 
ic measures were used, immediately upon stopping the 
constitutional treatment the trouble relapsed at once. 
The importance of syphilis as an adjunct in continuing 
inflammatory processes is well shown where infection 
(non-specific) attacks the mucous membrane, the process 
being under visual observation. Vaginitis of gonorrheal 
origin is thought to be quite common, in fact to be an 
accompaniment of all inflammations of the female genitals, 
but the fact is, the vagina is rarely involved. Occasion- 
ally we find it to be the case, but in the only two cases 
coming under my notice in the past three or four years 
the patients were syphilitic, one having the disease about 
six years with treatment only three months at the com- 
mencement, and the other having it about four years 
with interrupted treatment during that time. I may 
state that these two were from a series of about 25 cases 
of inflammation of the female genitalia, and although 
strong solutions of silver nitrate were used, without anti" 
syphilitic treatment the trouble seemed to remain at a 
standstill. Almost exactly the same condition is found 
in the male, but the inflammatory process not being 
within reach of the eye, excepting possibly by endosco- 
pic examination, (a very undesirable procedure in inflanr 
mation of the male urethra) we do not see the complete 
standstill that ensues in the presence of syphilis. 



CHAPTER VIII. 

CHRONIC SPECIFIC URETHRITIS 

CAUSES (CONTINUED.) 

LITHEMIA. 

That the condition known as lithemia plays an im- 
portant role in the prevention of resolution is a well 
known fact. When this is evidenced, as it is by a hyper- 
acidity of the urine which, if submitted to the micro- 
scope, shows a field covered by oxalates, uric acid crys- 
tals, etc., we see these as small, perfect, glass-like look- 
ing chips with sharp edges, and when the condition is 
marked the field may be entirely covered by them. Now 
imagine every drop of the urine to be simply saturated 
with these and this fluid to pass over a delicate mem- 
brane for at least nine inches. I grant that the same 
condition may be found in the urine of an individual 
never having an inflamed urethra and that they rarely 
cause trouble for the possessor, but when inflammation 
has once attacked the part they act as a powerful agent 
in maintaining the same. As stated before, the condi- 
tion may be present in an apparently healthy individual 
and the person pass through an attack of gonorrhea 
without developing these, but as a rule they are usually 
present. In a number of cases it may be the result of 



SIMLPE AND SPECIFIC URETHRITIS. 53 

some constitutional condition, such as rheumatism, or 
where digestion is faulty, but in a majority of the cases it 
is an acquired condition, this being due to medication 
and the want of hygienic precautions necessary in inflam- 
mations of the urinary tract. Probably one of the greatest 
causes of the condition known as oxaluria is due to long 
continued administration of copabia, cubebs, etc. These 
drugs, when long used, tend to produce a condition in 
the gastro-intestinal tract whereby assimilation is sadly 
interfered with, the result being the production of ox- 
alates in large quantities. I have seen a low form of 
urethral inflammation continued for nearly six months 
where by the most careful examination «no other cause 
could be found than the fact of a urine loaded with uric 
acid crystals, or the same in perfect solution. The urates 
may be considered a most prolific cause at times; espe- 
cially is this marked in those who are in the habit of 
consuming large quantities of malted liquors. Their 
urine is of a high color, high specific gravity, and if al- 
lowed to cool assumes a dirty color, becoming very 
opaque. A test for this condition, and it is said that 
this is the only condition of the urine where transpar- 
ency can be brought about from the same procedure, is 
to heat the liquid, when, if the opacity is due to urates, 
it becomes transparent at once. One other most im- 
portant factor in the production of oxalates, urates, etc., 
is diet and hygienic rules observed. All articles of food 
known to be rich in oxalates, etc., should be prohibited, 



54 SIMPLE AND SPECIFIC URETHRITIS. 

especially during the acute condition and to a certain 
extent during the chronic stage, provided there is a 
tendency to the condition known as lithemia, and if this 
is present they must be dispensed with entirely. All 
cases should be subjected to well directed hygienic 
rules, exercise and bathing being enforced, in this way 
ridding the system of much pent-up material that has a 
tendency to irritate the mucous membrane of the genito- 
urinary tract when allowed to pass over this membrane 
in excessive quantities. Under this heading, and as a 
condition of lithemia, we have the disease rheumatism. 
This, in connection with lithemia, I have found to be 
one of the worst impediments to resolution. 

PROSTATIC OR VESICULAR INVOLVEMENT. 

It must not be taken for granted that in the absence 
of symptoms referrable to these structures they may not 
be involved. Still, on the other hand, unless the in- 
volvement is acute, we do not find these parts affected 
unless the trouble has been long continued, subjected to 
the rough use of sounds, etc., or stricture exists. As 
before stated the anterior, and for that matter the pos- 
terior urethra, may become normal, as is evidenced by 
discharge or debris in the urine, yet from some excess 
in venery or the free use of beer, infection can take place, 
the infectious material coming from either the prostate 
or vesicles. Think of gonorrheal epididymitis developing 
months and even years after a supposed cure of an 



CHRONIC SPECIFIC URETHRITIS. 55 

acute gonorrheal infection that was not accompanied at 
the time by any testicular involvement. 

FOLLICULITIS. 

Jn the absence of a rapid cure of gonorrhea these 
small cavities in the urethra are often accused of being 
the fortress that is harboring the cocci and continuing 
the trouble. It may be safely stated that they are at 
times the source from which gonococci appear, thus in- 
fecting a membrane which may have been put in a nor- 
mal condition by injections or otherwise, but I will state, 
without fear of successful contradiction, that follicles 
harboring cocci which can appear en the membrane and 
cause trouble are rare. When there is a follicular in- 
volvement that can produce a condition as described 
above there will be symptoms that cannot be mistaken, 
and if appropriate measures are used the proof of their 
existence will be manifest by the entire disappearance of 
all inflammatory trouble. (See treatment of this condi- 
tion.) In the treatment of at least three hundred cases 
of chronic urethral trouble during the past four years, 
follicles that were harboring the infecting agent was only 
found in four cases. Among these one was an acute 
condition in a patient where from previous experience I 
was aware that unless resolution took place in due time 
folliculitis might be suspected. The discharge ceased and 
the urine cleared up, assuming a normal transparency, 
but upon discontinuing treatment the trouble occurred 



56 CHRONIC SPECIFIC URETHRITIS. 

at once. I again put the membrane in a nonnal condi- 
tion and at cnce looked for follicles, which I found and 
destroyed, this being followed by an immediate stoppage 
of all trouble. A case of chronic urethritis cannot be 
considered well until all evidences of inflammation dis- 
appear from the urethra, plus the other conditions al- 
ready referred to. At times cases are seen that, al- 
though there may be no discharge, and even if sexual 
intercourse and liquors are partaken of temperately, no 
trouble seems to manifest itself yet the urine does not 
clear, but contains shreds, etc. If these shreds are ex- 
amined they will be found to consist of degenerated epi- 
thelium, a few leucocytes, and possibly cocci, but not 
always of an infectious nature. Examination of the 
canal by the methods now in use (electric light) gener- 
ally shows that certain localized spots (usually in the 
deep urethra) are present where the membrane seems to 
be of a dark red color and slightly thickened. This can 
well be described as a localized inflammatory area and 
involving the submucous tissue. A condition of this 
kind should not be allowed to continue, for it is at these 
points that stricture is prone to form. (See treatment of 
them. 

IDIOSYNCRASY. 

There is not the least doubt but that in certain people 
there is some peculiar condition of the system that pre- 
disposes them to inflammations, and this is continued in 



SIMLPE AND SPECIFIC URETHRITIS. 57 

the absence of a well defined cause therefor. It cannot 
be said, as of catarrh, that climate is the cause, for the 
urethra is not a tube for the conveyance of air, and air 
never passes over it, except where it may be injected 
from a syringe or otherwise. Yet we do find individuals 
that, after the removal of every possible cause and the 
application of the most careful and appropriate treat- 
ment, still insist upon retaining a chronic or catarrhal 
condition of their urethras following a specific infection. 

WANT OF TONE IN THE TISSUES. 

This is of course only a manifestation of some other 
condition, and most of these have already been referred 
to. Although there may be no constitutional cause pre- 
sent, a person who has subjected his system to all sorts 
of abuse for a long time will find that upon the contrac- 
tion of a specific inflammation that he does not respond 
to remedies that are known to bring about a normal con- 
dition from one of disease. As an example of this kind 
of person the " social " man may be mentioned. During 
the winter months he subjects himself to the greatest 
kind of fatigue. Late hours, late suppers, usually con- 
sisting of every imaginable undigestible article that can 
be put on a table, excessive use of tobacco, and at times 
liquor, all these things, plus many others, have but one 
tendency, a system far below par as to resisting power. 
There is a class of individuals who, although they may 
not submit themselves to any of the intemperate habits 



58 SIMPLE AND SPECIFIC URETHRITIS. 

above referred to, nevertheless have no resisting power 
whatever in the tissues. These may be spoken of as 
lymphatics and their faces are the barometers. If their 
features are carefully scrutinized it is at once seen that 
that ruddy look of health is absent and a sort of pasty 
complexion is noticed, appearing as though they were 
almost bloodless. When these people are attacked by 
inflammation it seems to extend as rapidly as a fire in a 
bundle of shavings. Under this heading will come all 
constitutional conditions (see the same as a cause) 
either malignant or otherwise. Possibly one of the most 
important cf the latter class is Bright's disease. In the 
interstitial condition it is a well known fact that the pa- 
tient is rarely aware of his malady until applying for life 
insurance, or possibly not recovering from some appa- 
rently trivial urethral, prostatic or other trouble of the 
lower urinary organs, it is found when the urine may be 
examined for a possible case that chronic intestinal in- 
flammation of the kidney is present and is the one fac- 
tor that is withholding complete resolution in the parts 
mentioned. Chronic renal trouble is usually evidenced 
in some way by the urine, and in a large majority of the 
cases by a visual examination. Thus, when there is a 
continuous light colored fluid, always seeming to be in- 
creased in amount above the normal, the kidneys must 
be thought of as cause, careful examinations being made 
to ascertain if such be a fact of the general constitution- 
al condition. 



CHAPTER IX. 

CHRONIC SPECIFIC URETHRITIS 

CLINICAL EVIDENCES. 

It seems almost a loss of time to refer to the symptoms 
of chronic urethritis, yet, it must be remembered that 
while there is pus in the urine and this discharge, or no, 
is known to come from the urethra, the case must b^ 
classed as one of chronic urethritis and as such should 
receive treatment. Assume the condition present to be 
at about the eighth week and that the posterior urethra 
is, as it always is, involved, the usual history obtainable 
is about as follows : Moisture at the meatus urinaris, 
varying from a simple glueing together of the lips, a drop 
of fluid in density from that of pure water to a thick 
creamy pus, or a constant discharge all day resembling 
either of the latter in consistency. The discharge may 
have entirely ceased, to return at the least indiscretion, 
or there may be no return, but a visual examination of 
the urine will show (unless there is complete resolution) 
a diminished transparency, ranging all the way from a 
clumping of pus and mucous, accompanied by many fine 
shreds, to one of complete opacity, the urine resembling 
either diluted milk or cider. It may safely be stated 
that where the latter condition is found, and there is no 
discharge, the opacity is due to trouble behind the com- 
pressor muscle. This is more positively proven by using 



60 SIMLPE AND SPECIFIC URETHRITIS. 

the two glass test. To gain positive aid from the urine 
as a diagnostic agent the morning fluid should be taken ; 
that is, the first passed in the morning. It has been the 
author's findings .that to .thoroughly wash the anterior 
urethra at least two ounces should be caught in the first 
glass, the remainder in the second^ or where it is known 
that at least six ounces ma}/ be in the bladder this rule 
may be dispensed with and the patient told to divide 
the quantity as near as possible. If the first is most 
opaque, and this is the rule, there is no doubt that the 
anterior urethra is suffering more than the posterior. 
Should both glasses appear about the same, the trouble 
is more marked behind the compressor, and may be 
higher up than the internal sphincter. The first con- 
taining shreds with a slight amount of pus, the second 
also slightly opaque but with minute specks floating 
through it (prostatic plugs) is almost pathognomic of 
prostatic involvement. Although some of the plugs from 
the prostatic sinuses may be washed away and appear 
in the first glass, they are more apt to be in the second, 
and this is due to the fact that when the prostate closes 
down they are expelled. Excepting in severe involve- 
ment of the posterior portion of the canal, or in the pre- 
sence of a highly neurotic patient, but few subjective 
symptoms are complained of, with the exceptions of a 
slight increase in frequency which is always present. 
Occasionally there are slight neuralgic-like pains com- 
plained of in the groins, and these shooting towards the 



CHRONIC SPECIFIC URETHRITIS. 61 

testicles, but this is not entirely due to the urethral in- 
flammation, per se y but generally shows that the prostate 
is involved, and they are reflex manifestations of this to- 
gether with the trouble in the posterior urethra. A con- 
stant pain in one or both groins is sometimes present; if 
careful examination is made the inguinal glands will be 
found slightly enlarged. An occasional symptom com- 
plained of is the appearance of pus, or whitish material, 
at the meatus, after the bowels move and at times fol- 
lowing the urine. This is usually indicative of vesicular 
involvement, but spermatorrhea should be eliminated. If 
the discharge has been profuse and the length of time 
drawn out since the original infection, a careful scrutiny 
of the patient will show that he is suffering more or less 
from the continual drain. Questions will bring out the 
fact that such patients fatigue much more easily than be- 
fore they were infected. Unless there are complications 
present involving the prepuce or glans there is no ex- 
ternal evidence of anything wrong. Where the discharge 
is very profuse, the balano-preputial membrane may be 
involved and manifest itself in the shape of a marked 
balano-phostitis, and this at the same time may be ac- 
companied by phimosis or periphimosis. Quite a com- 
mon development about this time are venereal warts. 
They appear as little excresences, scarcely noticeable to 
the naked eye, but become larger rapidly, at times cov- 
ering nearly all the preputial membrane. Various ner- 
vous symptoms accompany this condition, and at times 



62 SIMPLE AND SPECIFIC URETHRITIS. 

these are especially marked in those patients of a neu- 
rotic temperament where the posterior urethra has suf- 
fered severely and the prostate is more or less involved. 
Emissions are of frequent occurrence, and should inter- 
course be attempted, ejaculation is premature and ac- 
companied occasionally by pain deeply in the perineal 
region, the semen being tinged with blood. When this 
occurs it may positively be assumed that the ejaculatory 
duct is more or less involved. Sudden darts of pain, 
starting near the rectum and extending to the glans, 
where there is a sort of explosion, is frequently encoun- 
tered. Much fear is experienced by the patient at seeing 
a drop of glycerine-like fluid appear at the meatus at or 
after defecation. This is supposed to be semen; it may be, 
but in the majority of cases where there has been no pre- 
vious trouble and no history of frequent emissions it is 
undoubtedly urethral mucus or prostatic fluid and is due 
to a hypersensative condition of the gland (prostate) or 
urethral glands. At times the patient thinks he can locate 
the trouble in his urethra by the slight irritation or itch- 
ing sensation experienced at a certain spot or spots. It 
cannot be advised unless absoutely necessary, but if the 
electric endoscope is used the canal will be found to be 
nearly if not normal in appearance at the spots described? 
the symptoms in question being simply a reflex manifes- 
tation of trouble at some other point, or when such oc- 
curs a day or two after the stoppage of medication it is 
usually a most positive sign that the trouble is relapsing 



CHRONIC SPECIFIC URETHRITIS. 63 

and will soon make its presence known by a return of the 
discharge. This localized irritation can in no way be 
taken as an evidence of follicular involvement, but in 
case where irrigations, even the first may stop all dis- 
charge, in fact clearing the urine off any and all debris, 
yet in twenty four to forty eight hours thereafter there 
is an irritation at or near the meatus, this soon (2 or 3 
hours ) being followed by a profuse discharge, follicular 
involvement should be suspected at once. Uufortunately 
for the medical profession there has never been a post- 
mortem obtained at this time (urethral pruritis) and for 
that reason a theory must receive attention. It is the 
author's opinion that where relapse occurs, either from 
a localized spot or follicle, the membrane at this location 
has not assumed a chronic condition, but is yet in a state 
of acute inflammation and being continued so, due either 
to bacteria in a state of activity, or, being dorment, they 
through some irritation either internal or locally, resume 
activity sufficiently to multiply the specie and upon the 
already weakened and congested tissues exert their power. 
Finger in his work on gonorrhea lays great stress on 
involvement of the caput gallinaginis as the important 
cause of most of the nervous symptoms seen in patients 
suffering from chronic gonorrhea. From most careful 
observation it is the author's opinion that although that 
portion (veru montanum or caput gallinaginis) of the 
anotomy may be involved, the prostate is also involved 
and is accountable for many of the symptoms. 



CHAPTER X. 

CHRONIC SPEGI FIG URETHRITIS 

DIAGNOSIS. 

It is scarcely conceivable how a mistake can be made 
in the diagnosis of chronic urethritis, yet cases are occa- 
sionally met with that necessitate the most careful exam- 
ination before being positive of the origin of the dis- 
charge and also the pus in the urine. To thoroughly 
understand the source of pus in the urine, particularly if 
when the two glass test is used, one must understand the 
physiology of urination. The urine enters the bladder at 
an average rate of about two ounces every hour (this is 
liable to great variation, weather, ingested fluids, disease, 
etc., at times greatly increasing or diminishing it), filling 
the same to a degree when the resistence of the internal 
sphincter is overcome and the fluid is allowed to enter 
the posterior urethra. As near as I have been able to 
judge this phenomena occurs in about two hours after 
previous evacuation. It is now seen that the posterior 
urethra forms what may be called the neck of the blad- 
der, and there is a direct opening between it and the 
bladder proper. Any substance that may be occu- 
pying that portion of the canal between the compressor 
and the internal sphincter at once mixes with the enter- 
ing urine and can pass backward into the bladder, there 



CHRONIC SPECIFIC URETHRITIS. 65 

becoming mixed with the bladder contents, rendering 
the same opaque. As nothing can pass from the ante- 
rior urethra backwards (behind the compressor) it is evi- 
dent that when pus is found in the second glass it is 
coming from behind the compressor. In the absence of 
gonorrhea, or where the case is of long standing, this 
secretion may be coming from other localities. (See ex- 
amination of the urine as to epithelium.) The two glass 
test is very necessary in every case ; in fact, the urine 
of a patient having chronic urethritis should be examin- 
ed in this way at every visit and careful notes made of 
the condition found. As heretofore stated, the morning 
urine should be the specimen examined where possible, 
(this must be seen when fresh, as standing renders it 
opaque, due to development of bacteria) but where this 
is an impossibility, patients should be instructed to hold 
it as long as possible, so as to pass at least two ounces 
in the first glass. (A four ounce glass is best suited as 
the receptacle, being about the size of a dollar at the 
base and gradually enlarging upwards.) Opacity varies, 
being from that of sour cider in both glasses to a slight 
turbidity of the first glass, containing shreds or chunks 
of pus, with a second glass so transparent that only 
centrifugalization and the microscope will show pus. 
On the other hand, about the same condition may exist, 
excepting the second is slightly more turbid, and float- 
ing in the same are seen numerous little specks (prosta- 
tic plugs) that have been occupying the mouths of the 



66 SIMLPE AND SPECIFIC URETHRITIS. 

prostatic sinuses and have been squeezed out as the 
bladder has contracted to expel the last few drops. Be- 
sides being a valuable adjunct in the diagnosis the two 
glass test with its contents is a good, if not the best, aid 
in judging the progress of the case. One thing is posi- 
tive, as the urine becomes cleaner shreds will appear, 
and the appearance of these indicate that the inflamma- 
tory process is becoming localized in certain spots. The 
appearance of shreds in a previously opaque urine is to 
me the most positive indication of progressive resolution 
being established. It is quite common to find semen in 
the urine of patients with inflammatory conditions of 
the posterior urethra, and unless one is very familiar 
with the appearance of pus or phosphates they may be 
easily misled into thinking that an increased opacity 
may be due to pus, etc. For this reason it is advisable 
to use the microscope in any case where the urine has 
been becoming cleaner day by day but suddenly becomes 
quite turbid. Although it has been stated that every 
case involves the posterior urethra at the time mention- 
ed other tests may be made where great accuracy is de- 
manded. A solution of methylene blue is injected slow- 
ly into the urethra, where it is allowed to remain for at 
least three or four minutes, so that thorough staining 
can take place. The syringe used for this purpose 
should hold at least half an ounce, for if a smaller one 
is used the injected fluid will not fill the canal to an ex- 
tent sufficient to dilate all the small crevices and folds 



CHRONIC SPECIFIC URETHRITIS. 67 

thus reaching debris contained therein. The urine 
should now be passed into two separate glasses ; that 
from the anterior urethra will be stained when anything 
from the posterior urethra will remain colorless. Care 
should be taken that at least two ounces or more of ur- 
ine is passed into the first glass, otherwise the second 
portion may bring forth shreds, etc., that have been 
closely attached to the mucous membrane and were re- 
moved only by continuous pressure. The same result 
can be obtained where blue is given internally, excepting 
that the debris, etc., in the posterior urethra will be 
stained, instead of that coming from the anterior urethra. 
With this procedure the urine must be held in the blad- 
der as long as possible, so that the posterior urethra be- 
comes a part of the bladder and thorough staining is al- 
lowed to take place. Washing the anterior urethra 
thoroughly is another method for obtaining the same re- 
sult, but should be done very carefully so as not to allow 
the water used to pass the compressor, thus carrying the 
anterior debris with it. The patient should be cautioned 
to hold the compressor tightly closed, as through trying 
to prevent urination. The best syringe for this purpose 
is the Ultzman, with the author's modification. Too 
much force must not be used, but the urethra should be 
distended until a sensation of dilation is felt by the fin- 
ger holding the penis, or the thumb on the piston shows 
the canal to be full and that the compressor is acting as 
an obstruction. This must be repeated several times, 



68 SIMLPE AND SPECIFIC URETHRITIS. 

until the water returns perfectly clear. Although the 
microscope is a most positive aid, one must be very 
familiar with the appearance of the epithelium from dif- 
ferent portions of the genito-urinary tract before too 
much dependence can be put on this instrument. (See 
epithelium chapter on urine.) A careful knowledge of 
the secretion found at the meatus is very necessary be- 
fore giving any positive opinion as to the condition of 
the urethral canal. There may appear at the meatus a 
morning drop or a continual discharge throughout the 
day, and yet there may be no inflammation in any part 
of the canal. On the other hand, this same condition 
may be present in a patient who has had a gonorrhea* 
yet the latter disease may be entirely cured. These 
secretions may consist of mucus, prostatic fluid or se- 
men, any one of which at times may resemble pus to 
such an extent that only differentiation is possible by aid 
of the microscope, Examples of such conditions are, in 
the case of mucus, ungratified sexual desire whereby 
there will appear at the meatus a drop of glycerine-like 
material that may be only momentary, or, as I have 
been told by patients complaining of such, there may be 
a decided moisture for hours. This is usually found in 
young men who have never practised the sexual act and 
will appear at the least provocation until it becomes a 
condition that is present to such an extent that they will 
complain of occasionally feeling a drop strike against 
the leg. This condition which is described under the 



CHRONIC SPECIEIC URETHRITIS. 69 

name of urethorrhea is not due to inflammation although 
it may follow in the wake of gonorrhea, and continue to 
manifest itself after all evidences of that disease have 
disappeared. This discharge consists simply of mucus, 
a few epithelial cells and leucocytes and is due to an irrita- 
tion of the mucous membrane with a hypersecretion from 
the glands of Cowper and Littre. This discharge must 
, be distinguished from prostatic secretion (prostatorrhea) 
which is thin, grayish, milky-like, having the peculiar seminal 
odor, is not tenaceous and upon the addition of a one per cent. 
solution of phosphate of ammonia, Boettchefs crystals are 
found, these being characteristic of prostatic secretion. On 
the other hand, urethral secretion is clear, (glycerine-like) 
has no seminal odor, is soapy-like to touch, quite tenaceous 
and at times causes glueing of the lips of the meatus. 
The loss of prostatic fluid other than at the 
time of sexual intercourse has a name for itself, prosta_ 
torrhea. Being as it is a subject of itself, readers will 
be left to consult some work dealing with it specifically. 
Suffice it to say that the microscope will quickly decide 
in making a differential diagnosis from pus, etc., by 
finding the prostatic elements present. The secretion 
may appear simply as a morning drop, or the meatus 
may be continually moistened by it It is the author's 
opinion that of all abnormal secretions found at the 
meatus, prostatic fluid, alone, is the rarest, in other words, 
true prostatorrhea is a very rare disease. 



CHAPTER XI. 

CHRONIC SPECIFIC URETHRITIS 

INFECTIOUSNESS. 

There is no doubt that acute gonorrhea is one of the 
most infectious diseases with which the human race has 
to contend, but where this infectiousness ends is a much > 
disputed point. This should not be, knowing as we do 
the germs that are capable of producing inflammation, 
that these are easily demonstrable by aid of the micro- 
scope, and a little technique that should be familiar to all. 

In all gonorrheal inflammations of the urethra at least 
three forms of pus-producing cocci are found, and it 
seems that until these are absent infection is possible. 
It may not necessarily be a gonorrheal infection, but a 
simple inflammation due to the staphylo (see plate) or 
streptococci (see plate) a condition that is almost if not 
as severe as one due to the gonococci. (See plate.) If 
we must believe the general surgeon who fears these 
germs, why should we not fear them, knowing, as the 
microscope will prove, that they are present in the small 
shreds found in the urine which passes through a canal 
not positively free from inflammation ? We must cer- 
tainly believe the above to be a fact, therefore an un- 
qualified answer would be an absence of pus cells, gono, 
strepto, or staphylococci, in fact the washings of the 
urethra should show that inflammatory action had en- 



PLATE II. 









EXPLANATION, PLATE II. 

In the upper two thirds is shown pus cells as seen with 
the oil immersion lens, the nuclei being stained with 
methylene blue. 

Streptococci, in and around the pus cells. 

The chain-like formation shown, is the characteristic 
manner in which these cocci appear. 

(The following is as seen with the i-6th obj.) 

In the lower one third is shown pus cells, singly and 
in a cluster the nuclei being brought out by acetic acid. 

The clumping of the pus cells as shown, together with 
other findings in the urine, plus renal symptoms (at times 
only slight pain in the lumbar region on deep pressure) 
is almost pathognomic of involvement of the renal pelvis 
by inflammation. 

Above the pus clump is seen pelvic epithelium in 
shingle-like formation, this also being very characteristic 
of involvement of that locality. 

To the right may be seen blood cells having the ap- 
pearance of being some time in the urine since escaping 
from the vessels. 

73 

The accompanying plate is an exact 
reproduction from a case of the author's 
with the camera lucida, Spencer 1-1 2th oil 
immersion lens and methylene blue as the stain. 



74 SIMPLE AND SPECIFIC URETHRITIS. 

tirely ceased. Although there should be no appeal from 
the above, it must be taken into consideration that at 
least six out of every fifteen men have at some time of 
their lives suffered from gonorrhea and that it is rarely 
if ever the canal reaches the condition it was in previous 
to involvement. In other words, a urethra that has once 
been damaged by a specific inflammation will always 
show some evidence of the same. Such evidence is 
found in the urethral debris, this being brought forth by 
aid of the urine and is usually visible to the unaided eye 
in the form of shreds (tripper-faden) or chunk-like form- 
ations. It depends entirely upon the formation of the 
above mentioned whether the condition is serious or no. 
Where careful microscopical examination shows (the 
almost invisible shred to the naked eye) only a few de- 
generated epithelial cells, mucus in excess, possibly only 
a dozen or more pus cells and a few small sized strepto. 
or staphylococci, but little fear need be experienced of 
any bad result following marriage, provided of course 
other well known fortresses for infection have been ex- 
amined and found free from involvement. Where there 
has been epididymitis, vesiculitis, or prostatitis present 
it is well, even in the face of a urethral condition as 
above, to have the patient first urinate, then, with the 
use of a condom, perform the sexual act, bringing the 
contained secretion for careful examination. If the 
spermatozoa are found to be undersized, withered-like in 
appearance and pus cells are present, (see pus cells in 



CHRONIC SPECIFIC URETHRITIS. 75 

plates I, II, III, IV,) consent by no means should be 
given until the part is rendered normal, as will be shown 
by healthy, full-grown spermatozoa and the absence of 
pus cells. Much might be said as to mixed infection, 
but my readers can only be referred to some good book 
on bacteriology, as the consideration of such a subject 
would be beyond the scope of this small work. 

PROGNOSIS. 

Much must be taken into consideration as to what 
constitutes a cure of gonorrhea. If, on the one hand, 
we accept the opinion that a gonorrhea is never cured 
until the urine (most minutely examined) shows positive- 
ly no evidence ot any inflammatory action being present 
along the genito-urinary tract, it is seldom a cure is ob- 
tained. To look at it from a more conservative stand- 
point, a cure beyond infection, or damage to the posses- 
sor, is possible. Certainly my words can be verified by 
a little questioning on the part of the physician, and.it 
will be found that many men who had gonorrhea in their 
younger days are now married, and neither they or their 
wives ever complain of the least symptom that might be 
referable to the result of early indiscretions. There is 
no doubt that a good prognosis could be given in almost 
every case, provided irritation was avoided, and the con- 
dition treated in a rational manner, although it might 
not exactly tally with the opinion of some supposed 
great authority upon the subject. There is no doubt 



76 SIMPLE AND SPECIFIC URETHRITIS. 

but that many men have been rendered sterile or impo- 
tent by the too frequent passage of sounds at the wrong 
time. Although these instruments are very necessary 
in the majority of cases in aiding the absorption of in- 
flammatory deposits of the mucous membrane, they are 
at the same time just as injurious if used too frequently 
when not necessary. (See use of sounds in treatment.) 
The general surgeon is seen to scrub and wash the part 
to be operated upon until the epidermis is removed, and 
this he tells us is for cleanliness, to prevent infection, 
yet if the same man is to pass a sound the canal receives 
not the slightest attention. In the large majority of 
cases where a sound is necessary there is trouble in the 
canal and this of an inflammatory nature, producing pus. 
Generally the patient is not asked to urinate, but the 
sound is passed forcing any debris that may be present, 
not cnly into the follicles of the anterior urethera, but 
into the prostatic sinuses, and wonder is expressed why 
the patient developed an epididymitis, follicular prostatitis 
or other complication. The complication is relieved and 
treatment renewed but only to find that the condition 
does not improve, in fact is worse if anything. The pa- 
tient may, after weeks or months of suffering, seek or be 
sent to the specialist who at once finds that some portion 
of the genital anatomy has been so seriously involved 
that it is a grave question whether it will ever be possible 
to again bring the parts to a normal condition. 



CHAPTER XII. 

CHRONIC SPECIFIC URETHRITIS 

URETHRAL ANTISEPSIS. 

Infection of the urinary tract arises from two sour- 
ces, internal and external. Of these internal causes 
no one now doubts that the colon bacillus can and does 
enter the kidney from the blood stream. But that these 
germs can cause nephritis per se is much in doubt. In 
cases of pyelitis accompanying calculus, infection from 
below being excluded, there seems to be no question 
that they are offending agents. The same may be said 
of the bladder. Other conditions become predisposing 
causes, as phosphaturia. In these cases I am of the 
opinion the bacilli find their way by migration from the 
rectum. With the exhaustive research and valuable lite- 
rature that has appeared in the last few years in relation 
to genito-urinary tuberculosis, it is quite unnecessary to 
refer to this subject. A form of microorganism most 
frequently found in the urine, the origin of which is ob- 
scure, but the cause easily traceable, may be described 
as (a) spherobacteria or micrococci ; (b) microbacteria ; 
(c) desmobacteria. (See fission fungi, page 17.) 

Whether these germs per se can produce inflammation 
is a question yet unanswered ; but that they can produce 
and maintain a congestion is well known, A congestion 



78 CHRONIC SPECIEIC URETHRITIS. 

is fertile soil for pyogenic bacteria and as the colon ba- 
cilli are found in nearly all of these cases, it is yet unfair 
to say the first named are the sole cause of the inflam- 
matory trouble. 

Involvement of the genito-urinary tract from without 
needs no description. Omitting the gonococci as a cause 
when infection occurs, please charge yourself with its 
production. Still this does occur every day, and how T ? 
The abdominal surgeon will scrub both patient and him- 
self until the epidermis is removed, the obstretician his 
hands until the same occurs, yet every day catheters, 
sounds, bougies and cutting instruments are used in the 
urethra and bladder without the least sign of cleansing 
of the field, except possibly the parts external. Again, 
we must look at this in a different light, for where cathe- 
ters, sound and urethral or bladder instruments are nec- 
essary, trouble has and does exist. This trouble is the 
result of inflammation : inflammation is due to germs, 
and these can be and are carried by instruments ; and, 
lastly, the irritation produced by instrumentation makes 
a good soil for germ culture. I will grant the fact that 
it is seldom a cystitis is produced by the passage of a 
sound or catheter, but one such, caused by one of these 
^struments will give the producer and incidentally the 
patient something to think of. 

One of the most frequently used remedies for the cure 
of a chronic gonorrhea is the sound,**but why invariably 
a failure ? Because it is not used in the proper time and, 



SIMPLE AND SPECIFIC URETHRITIS. 79 

* 

furthermore, it is passed through a canal filled with pyo- 
genic cocci and no precaution is used to allay the irrita- 
tion produced in its passage. 

A urethrotome or cystoscope is boiled or otherwise 
sterilized until a culture could not be obtained, but these 
same instruments cannot help but become infected be- 
fore they have traveled one inch inside the meatus. 
There are but two or three conditions where a urinary 
catheter is necessary : (i) in the female ; (2) prostatitis 
or hypertrophy with obstruction, or where there is no ob- 
struction, but we wish to ascertain the amount of resi- 
dual urine ; (3) when we wish the patient to thoroughly 
empty the bladder daily. 

Summing up the foregoing thoughts, but one conclu 
sion is reached : 

(1) Abandon the catheter foreve, except in conditions 
heretofore mentioned. (2) Precede the sound or any 
instrument that is to traverse the urethra by an antisep- 
tic solution, nothing being better than formaldehyde. 
(3) Following the passage of an instrument always fill 
the bladder with an antiseptic astringent, allowing the 
patient to immediately pass the same. This will allay 
the irritation produced. 

Irrigation of the urethra or bladder, I am pretty safe 
to say, was used in the days of John Hunter, and now 
the apparatuses for its performance are almost as nu- 
merous as genito-urinary surgeons, for no one would 
consider himself such unless he had put upon the mar- 



80 SIMLPE AND SPECIFIC URETHRITIS. 

ket such a contrivance. It will be unnecessary to con- 
sider the apparatuses for urethral cleansing further than 
to say, in the hands of their inventor, they will fulfill 
their calling successfully. For the inexperienced much 
pratice is necessary and while this is being attained both 
patient and surgeon must suffer. One with epididymit- 
is, cystitis, soiling clothing, and the like; the other dis- 
colored hands and an occasional douching, due to splat- 
tering of the fluid. Clumsy wall decorations are neces- 
sary and there is always more or less breakage; lastly, 
most are expensive. 

FIG. 2 




Ultzmann syringe, with author's attachment. 

The apparatus I propose to advocate for this work is 
a syringe (capacity, 6 oz. Fig. 2), with a long nozzle, 
having attached to it a cup-shaped shield, the concavity 
looking outward. With it there can be no soiling of the 
clothing or hands: the hand controlling the piston can 
measure the resistence of the urethra and also that of the 
bladder. (Cases of tubercular cystitis, where to me this 
one point— bladder capacity—is the most important symp- 
tom of that disease.) 

The anterior urethra is easily cleansed: every rugae of 



CHRONIC SPECIEIC URETHRITIS. 81 

the mucous membrane being distended, thus allowing the 
solution to come in contact with the whole surface, 
The syringe is inexpensive, can be easily handled and 
is made positively sterile in half a minute. 

Conscientiously, I cannot recommend internal medi- 
cation for the destruction of bacteria developing along 
the genito-urinary tract; furthermore, urinary antiseptics 
have been over-estimated, except in tubercular condi- 
tions, where creosote or its derivatives will to a certain 
extent prevent the growth of these specific bacteria. To 
be sure, drugs recommended for this purpose, when 
placed in freshly passed urine, will keep it for a longer 
time without their development than if no drug was used, 
but the same drug passing through the system, meeting 
as it does the different chemical substances, to my think- 
ing, are so changed that when it reaches the urine the 
power of bacterial destruction is destroyed. Bacteriuria 
has a definite cause ; discover and remove this and 
these germs will disappear from the urine. Of the nu- 
merous cases which I have been called to operate upon 
for retention, extravisation and the like, with but an 
hour's notice my results have been just as good as 
though these patients had been medicated for three or 
four days previously in trying to obtain an impossibility. 
Remember it is just as possible to have an antiseptic 
operation field as it for the abdominal surgeon to have 
the same. 



Chapter 12 is extracts from a paper read before the Surgical' Section, Buffalo 
Academy of Medicine, March 1899 and appeared in the Buffalo Med. Journal. 



'82 SIMLPE AND SPECIFIC URETHRITIS. 

The following history will show the value of the pre- 
liminary wash: L. L. aet. 68 W< gonorrhea several times 
in younger days. About 25 years ago first noticed that 
urine was coming witn difficulty and finally retention de- 
veloped, tried to catheterize himself, breaking instrument 
(rubber) in canal ; operation was necessary for removal. 
Following this stricture was dilated but again contracted, 
and about 10 years ago necessitated dilation, this being 
immediately followed by a chill, lasting 4 or 5 hours. 
Urethratomy (external) was performed next day, and as 
before was followed by a chill. In the following years, 
up to August 31st, 1900, he was cut 4 times and dilated 
times innumerable, each seance being followed by a 
severe chill. At this time the patient consulted the au- 
thor, complaining of being only able to pass urine in 
drops. Examination showed a filiform stricture in the 
deep urethra, which was very irritable. Before attempt- 
ing dilatation the patient, although a toughened old 
tar, exhibited much fever, which, upon questioning for a 
cause therefor, brought out the fact that in the past 10 
or 12 years he had never had a sound or instrument 
used in his canal that was not followed by a chill lasting 
from 4 to 6 hours, and he dreaded the after effects of 
the instrument to be passed. I assured him there would 
be no chill this time and the canal was thoroughly flush- 
ed with'formaldehyde solution (1 to 1500), after which 
a filiform was passed and a No. 12 F tunneled sound 
(see treatment of stricture below 20 F) made to override 



CHRONIC SPECIFIC URETHRITIS. 83 

it. After innumerable visits, none of which was follow- 
ed by the least disturbance, it was apparent that, owing 
to the dense cicatritial tissue (due to frequent operations) 
dilatation above 15 F was out of the question and oper- 
ation was again advised. The patient did not return 
until contraction had taken place to an extent that urine 
was voided only in drops. On January 12th, 1901, ex- 
ternal urethrotomy (30 F) was performed, after thorough- 
ly flushing the canal, as previously mentioned. On the 
eighth day a No. 30 F sound was passed and the house 
surgeon instructed to wash the bladder daily with a silver 
solution (see argentum solutions for chronic urethritis). 
As he did not have an Ultzmann syringe a sterilized 
catheter was passed, but without any preliminary flush- 
ing. In a very short time a severe chill fullowed, last- 
ing 2 1-2 hours. Since that time at least a dozen sounds 
have been passed and at no time was there any indica- 
tion of rigor. Rigors following urethral instrumentation 
is well known to be due to other than sepsis, and in 
this case, occurring as they did within two hours after 
treatment, leads one to think that a nervous phenomena 
played an important part in their production. Yet, 
nevertheless, it must be taken into consideration that 
this patient had a marked pyelitis, with a urine contain" 
ing much albumin, and that every seance was accompa- 
nied by more or less blood, denoting some traumatism 
at the strictured portion of the urethra, but, when anti- 
septic flushing preceded a sound, there was no constitu- 



EXPLANATION, PLATE III. 

Staphylococci, in and around the pus cells, also within 
c ell wall of the round epithelial cell. 

Pus cells — Some have apparently two, while others 
have three and even four nuclei. 

It is now taught that a pus cell is a sphere having but 
a single nucleus, this being very irregular in shape and 
when brought out by acetic acid, or staining, it is the 
position the cell occupies that gives it the appearance of 
having several nuclei. 

Caudate or spindle shaped epithelium. 

Round epithelium. 84 




The accompanying plate is an exact 
reproduction from a case of the author's 
with the camera lucida, Spencer 1-1 2th oil 
immersion lens and methylene blue as the stain. 



PLATE III. 



& ^s 





CHRONIC SPECIFIC URETHRITIS. 87 

tional disturbance. In this case the prostate was mark- 
edly large, practically caused by the inflammation due to 
the obstruction, but hypertrophy was much in evidence. 
The condition was explained to the patient, he giving 
us liberty to remhve the gland if it was thought anp ben- 
efit would result therefrom. After opening the bladder 
and careful examination by Dr. J, F. Meyer and the 
author it was concluded with the existing bladder con- 
dition (chronic interstially inflamed), and taking into 
consideration that the patient had pyelitis, with at least 
20 % of albumin in the urine, prostatectomy was contra- 
indicated, as death would surely follow. Excision of the 
stricture was to be attempted, but owing to the previous 
operations the cicatritial tissue was so dense and en- 
croached upon the surrounding parts to such an extent 
that removal was out of the question. 




CHAPTER XIII. 

CHRONIC SPECIFIC URETHRITIS 

HISTORY. 

Although the main symptom of chronic urethritis is 
much in evidence at all times, success in treatment can- 
not be hoped for unless the most searching enquiry is 
made and every portion of the genital anatomy examined 
at the first visit, excepting the urethra, which should re- 
ceive no attention until the inflammatory action has al- 
most if not entirely subsided. Urethral contraction, even 
well developed stricture, may be present, but if irritation 
is avoided and appropriate treatment carried oat the 
urine at a certain time will show their presence. Pos- 
sibly one of the first requirements is a careful observa- 
tion of the patient's general condition : is he well nour- 
ished, does there seem to be any power of resistence, 
does the facial expression denote a constant worry over 
the condition present? In fact, does the patient's con- 
dition show that the system is capable of doing its part 
towards hastening resolution in the membrane. The 
following questions will give some clue as to the line of 
inquiry that should be followed : 

Discharge, morning drop or all day. 

Character of. 

Date of appearance. 



EXPLANATION OF HISTORY CHART. 

For any of my readers who may wish to adopt a cut 
of this or other portions of the body, with or without the 
annexed questions, it may be of advantage to state that 
l i red ink is used for filling in. or the form printed in red, 
using black ink, much valuable time is saved when wish- 
ing to consult for reference. If using a similiar diagram 
the trouble can be marked as follows; a line through the 
secreting portion of the kidney and marked A. P., C. P., 
Inter, or Diffuse, indicates at a glance, Acute Parenchy- 
matous, Cnronic Par,, Interstitial or Diffuse nephritis. 

A line through the pelvis and marked R. or L., would 
indicate Pyelitis, the same involving the right or left 
kidney as the case may be. The Bladder, Prostate, 
Urethra, Testicles, etc., can be marked in the same way. 

In case of stricture, their location and size can be so 
inbicated that no mistake is admissible even in years 
afterwards. 




phag.. 
Oper... 

URINE day... 

Desire to pass... 

before, during 
Blood, before, with 

deep, perineum, prostate V 

Amount oz. Coir... 

Sp.G Reac. 

Opq... 

R. Ovary Tube... 

Second i L. Ovary Tube. . . 

Shreds pros.plugs...,...|Leucorrhea 



CHRONIC SPECIFIC URETHRITIS. 89 

Incubation. 

Urinates, days, nights. Was blood ever present. 

Desire necessitates (quick response or can wait.) 

Pain, before, during or after. 

Irritation, at meatus, penile, deep or prostatic urethra. 

Epididymitis, epididymo-orchitis. 

Perinaeum, swollen. 

Prostate, vesicles, cystitis, prepuce, gonococci. 

Coitus since infection, liquor during present condition. 

Previous attacks, first lasted, second lasted, etc. 

Epididymitis with, cystitis with, strictures (treated for 
by dilatation or cutting.) 

Retention of urine, fistulae, present condition of epidi- 
dymis as to nodules, etc., history of syphilis, chancroids, 
herpies, and in fact anything that may aid in the forma- 
tion of an opinion valuable to not only the patient but 
yourself. 

The urine should receive careful attention, not only 
chemically but microscopically. Much depends upon 
the appearance of this liquid, and the physician is care- 
less who does not examine it by the two glass test when- 
ever dealing with a case of urethral inflammation. (See 
clinical indications.) 

The patient's general condition must be taken into 
consideration and careful enquiry made as to tuberculo- 
sis, rheumatism, gout, etc. (See fac-simile page from 
author's history book. 



CHAPTER XIV. 

CHRONIC SPECIFIC URETHRITIS 

THE TREATMENT OF CHRONIC GONORRHEA. 

Older members of the profession who recall the teach- 
ings and literature of their younger days must be some- 
what surprised to see to what extent this subject re- 
ceives attention in works of today. Bryants Surgery, 
written in 1876, refers to gleet in two lines, and a work 
published in 1880 on venereal diseases devotes eight 
lines to chronic gonorrhea or gleet. During the last five 
years there certainly has been a deluge of works upon 
genito-urinary diseases, all of which give marked atten- 
tion to the subject under consideration. Yet it is a daily 
occurrence to see patients who have been treated by 
these very latest methods continue to have the same 
morning drop, or even have the condition aggravated. 
It seems there should be some excuse for such a condi- 
tion of affairs. A solution worthy of careful considera- 
tion is : the part is irritated rather than soothed. Most 
writers advise a searching of the canal at once for stric- 
ture or contractions which may be the cause of the 
trouble. Without hesitancy it may be stated that this 
one procedure is the great cause of continuing the 
smouldering fire. Various instruments are on the mar- 
ket and highly extolled as a mode of ridding urethral 



CHRONIC SPECIEIC URETHRITIS. 91 

follicles of their contained secretion, or for squeezing 
out sub-mucous inflammatory deposits. To use these a 
rubber covering is necessary so that the blades may not 
catch the mucous membrane. Is there a doubt that this 
rubber, no matter how well lubricated can pass over a 
most delicate membrane, already inflamed, without caus- 
ing more irritation? Iustruments of this character should 
not be used in the urethra no matter what condition the 
membrane is in. Careful consideration should be given 
to the facts already stated, for progressive resolution 
should not be considered at a standstill until after the 
eighth week, and nothing should be done in the way of 
office treatment until that time has elapsed The old 
idea held by the laity that a gonorrhea was not as bad 
as a cold is fast dying cut, yet a goc dly number of pa- 
tients present themselves who have endeavored to cure 
themselves by zinc injections, bal.copabia, and all sorts 
of patent nostrums. Still a greater number might be 
considered second handed for the reason that they have 
been under the care of one or more physicians before 
consulting the readers. When the latter is the case it 
may be safely assumed that the patient has been sub- 
mitted to all sorts of instrumentation, leaving us to deal 
with a membrane irritated to the highest degree. In a 
condition of this description, and it will not be amiss to 
make it a rule in every case that has net been under your 
care from the outset, to u^ the most soc Mng, non-irritating 
means at your command for at least ten days to two weeks. 



92 SIMLPB AND SPECIFIC URETHRITIS. 

This is best accomplished by an astringent injection, 
having the patient use the same at least three times a 
day. (See fig. i and foot note.) The following has 
given good results : 

Ijk Zinc Sulfate, grs. 24 

Alum, powdered, grs. 30 
Aqua, ad. ozs. 8 

Sig. Use a syringe full three times a day. 

In old cases, where the membrane is in a state of 
general inflammatory thickening, this at times involving 
its entire thickness ; better results may follow the addi- 
tion of some depleting drug, such as Ichthyol. This 
may be added to the above in a proportion of about one 
drop to each syringe full of injection, or say 25 drops in 
an 8 ounce mixture. 

It will be surprising to see the result obtained in most 
cases from such an injection. But much opposition will 
at times be met from the patient who will tell you he 
has been injected for anywhere from six or eight weeks 
to as many months. This must not interfere with the 
course which you should follow ; he should be candidly 
told that with but few exceptions (tubercular or cachec- 
tic) all these conditions are curable and there is no ex- 
ception, if treatment is carried out as you advise. 

A very careful observation of every case is necessary 
and where such conditions as anemia, syphilis, tuberculo- 
sis, uric acid or other cacexias exist appropriate measures 



CHRONIC SPECIFIC URETHRITIS. 93 

must be taken. It must be remembered that every case is a 
law unto itself, and no routine treatment will cure all. If 
epididymitis is present all local measures to the mem : 
brane must be stopped until the pain in the affected 
part is entirely absent. When there is prostatic involve- 
ment, excepting in acute parenchymatous, treatment, may 
be carried along at the same time as that of the urethra. 
Vesiculitis, if chronic, should also receive attention in 
connection with that of the urethra. After the twelfth 
or fourteenth day ot self-injection (by the patient), and 
providing that the advised eight weeks have elapsed 
since infection, local medication may be commenced and 
should be carried out daily, excepting under certain con- 
ditions to be mentioned later. The urine must be passed 
in two glasses at each visit (at least two ounces in the 
first) and carefully examined visually or otherwise to 
note progress of condition. It must be remembered 
that as general inflammation subsides and becomes 
localized only at certain spots the urine will become 
more transparent until practically nothing but shreds 
will appear in the first glass, the second being almost if 
not perfectly clear. (The inflammatory exudate is the 
only substance under consideration, phosphates or semen 
not being considered.) The best sign of improvement 

AS TO URETHRAL INFLAMMATION IS THE APPEARANCE OF 
SHREDS IN THE URINE. 

Knowing now that the case has not been irritated for 
at least 12 or 14 days we may expect to find about the 



94 SIMPLE AND SPECIFIC URETHRITIS. 

following condition : Slight discharge all day, or, possi- 
bly, only a morning drop, no objective symptom what- 
ever, the first urine opaque, ranging in degree where it 
may be almost possible to read fine print when held be- 
hind the glass to one where it is impossible to see 
through the fluid. The second glass will usually be of 
about the same character, but of a lesser degree. Occa- 
sionally there may be no evidence of discharge, but both 
samples of urine may be almost exactly of the same 
opacity, the first showing shreds. Such a condition 
clearly indicates that the inflammation has entirely sub- 
sided in the anterior urethra, excepting at one or more 
small spots, and the posterior urethra is the seat of the 
trouble. Still other cases are met where there may be 
little or no discharge, yet the urine will be opaque to a 
degree far beyond the evidences at the meatus. Thus 
the first appears only slightly opaque, where the second 
will look much like milk, and there may even appear at 
the meatus one or several drops of pure pus (these of 
course after the urine has ceased to flow.) This condi- 
tion is the most positive evidence of vesicular involve- 
ment. As has already been stated, and it should be accepted 
as a fact, at this time the posterior urethra is always involved 
and therefore should receive the same attention as that of the 
anterior urethra. Undoubtedly the quickest and least 
irritating way of applying solutions to the canal, either 
anterior or posterior, to the compressor muscle, is with 
the Ultzmann syringe, having the author's attachment, 



CHRONIC SPECIFIC URETHRITIS. 95 

(see cut), no catheter being used. If the patient is as- 
sured that there will be little or no pain, and as pressure 
is exerted upon the compressor muscle, he will try to 
urinate immediately following this with a suction motion 
in the canal, the fluid will readily pass the muscle and 
they can feel it entering the bladder. 

The best mode of using the syringe is to grasp the 
glans between the thumb and the first and second finger 
of the left hand, with the right thumb acting as the pro- 
pelling power, push the piston forward depositing about 
one half ounce of the fluid in the urethra. This should 
be let out at once by relaxing the grip on the glans, and 
the same procedure repeated two or three times. The 
second finger of the left hand will act as a meter in meas- 
uring the amount of dilatability of the canal, this always 
filling to its utmost capacity before the compressor opens. 

In practicing this little procedure it is evident that 
the anterior urethra is free of all debris, a condition that 
is absolutely necessary not only before allowing solutions 
to enter the posterior urethra, but any instrumentation. 




EXPLANATION, PLATE IV. 

Gonococci situated in their characteristic grouping in 
and around the pus cells. 

It will be noted that a single coccus resembles a cof- 
fee bean, but they are usually found in pairs and may 
occupy any portion of the field, intercellular, extracellu- 
lar, and occasionally may be seen upon epithelial cells. 

The following is diagnostic of these cocci, but where 
great accuracy is desired, as in a medico-legal case, the 
Gram's stain and culture must be used : 

i. Dipolococci, about i millimeter in size. 

2. Occurring in colonies, usually intracellular. 

3. Characteristic history with symptoms of the disease. 
Mucus, round epithelium, pus cells. 96 



0h 



The accompanying plate is an exact 
reproduction from a case of the author's 
with the camera lucida, Spencer 1-1 2th oil 
immersion lens and methylene blue as the stain. 



PLATE IV. 




CHAPTER XV. 

GHROMIG SPECIFIC URETHRITIS 

THE TREATMENT OF CHRONIC GONORRHEA, (CONTINUED.) 

Although one syringefull of the solution is all that is 
necessary for each treatment, if time permits, two may 
be used with possible increased value. The solutions 
to be used may be kept in stock, should be used warm, 

and THE SILVER SOL. MUST BE MADE WITH DISTILLED 

water. A zinc. sol. can be made as follows and used- 
as dilution i, 2, 3: 

Stock sol. Zinc, sulfate, grs. 540 
Alum, pow'd grs. 710 
Aquae drs. 300 

M, and keep in tightly corked bottle in dark place. 



Dilution 1— Of solution 


2 drs. 


water 6 ozs 


Dilution 2 — Of solution 


3 drs. 


water 6 ozs 


Dilution 3— Of solution 


6 drs. 


water 6 ozs 



Stock solution for silver injections : 

Jfy Argentum nitrate, grs. 96 
Aquae dist. oz. 1 

M. 20 °/c sol. (must be kept in black bottle.) 
L.ofC. 



100 SIMPLE AND SPECIFIC URETHRITIS. 



rops of above 


Aqua dist. ozs 


Equals 


2 


12 




1. 14000 


2 


io 




1-12000 


2 


8 




I-IOOOO 


2 


6 


1-2 


1- 8000 


3 


6 


1-2 


1- 6000 


3 


S 


1-2 


1- 5000 


4 


6 


1-2 


1- 4000 


5 


6 




1- 3000 


6 


6 


1-2 


1- 2000 


i4 


6 


1-2 


1- 1000 


18 


6 




1- 800 


21 


6 




1- 500 



OFFICE TREATMENT. 



As only practical experience with the urine for a long 
time can tell when the silver solutions are called for in 
the commencement of treatment, it is always best to 
start with the zinc and alum, in every case continuing 
the same for at least two or three days. (Fig. 2.) Dilu- 
tion No. i first day, No. 2 the second, and No. 3 the 
third, if thought necessary. At the end of the second 
or third day with the zinc alum, silver should be substi- 
tuted, commencing with 1-14000, increasing according 
to table until there is no discharge and the urine be- 
comes clear, excepting the shreds in the first glass, 
which will not disappear by injection, but must receive 
attention from the sound. There is no telling when 



CHRONIC SPECIBIC URETHRITIS. 1 01 

discharge may cease and- the urine clear, but from a 
large number of cases the author has found this to occur 
when about 1-5 or 6000 is reached. If the above con- 
dition is attained, about this time it is well to let the 
patient rest untreated for say three or four days, when, 
if there is no return of the discharge, (the urine may 
show a slight increase in inflammation) the cause should 
be sought for and removed if possible. When the dis- 
charge does not stop at about 1 to 5000 the irrigations 
must be continued until such a time as it discontinues 
and the urine becomes clear, excepting possibly the 
shreds indicating localized inflammatory spots. A rule 

THAT HOLDS GOOD IN ALMOST EVERY CASE IS I NEVER 
PASS ANY INSTRUMENT INTO THE URETHRA UNTIL THE 
URINE IS ALMOST IF NOT ENTIRLY CLEAR. The Causes 

of continued trouble in the urethra will be mentioned 
and described in order of frequency, as near as possible. 

EARLY AND PERSISTENT INTERFERENCE. 

Robert Taylor, in his work on diseases of the sexual 
organs, when speaking of the treatment of posterior ure- 
thr itis, and this should refer to inflammations of the an- 
terior urethra, says : " The duration of the urethrites 
has an important bearing upon its treatment." This is 
a very important statement, but furthermore, when a ure- 
thritis becomes chronic, and especially posterior, the older the 
condition (urethral inflammation) the quicker the cure. As 



102 SIMPLE AND SPECIFIC URETHRITIS. 

heretofore mentioned, there is no doubt that the early 
and persistent interference is the one, and in most cases 
the only cause, of continued inflammation of the ure- 
thra. If this is kept continually befcre one's mind suc- 
cess will be more often the result It must therefore be 
remembered that until progressive resolution has entire- 
ly ceased no interference should be undertaken to hurry 
a cure by instruments, office injections or otherwise. 
This demonstrates one fact : if the first injection seems 
to aggravate the condition the patient must be placed 
upon the hand syringe until such a time as office treat- 
ment may be commenced and rapid results follow. Above 
all things, instrumentation of any and all kinds must be 
dispensed with until the urine shows that the general in- 
flammation is subsiding and becoming localized at cer- 
tain spots along the canal. When this condition is 
reached the urine and the history of the case will give 
much information as to the cause of the continuation of 
the trouble. One thing is evident, strictures as a rule 
grow very slowly and unless there has been a previous 
infection years ago, and of long duration, or the present 
condition has extended over many months, well marked 
stricture need not be thought of. Where the above may 
be present, as is evidenced by the history, the urine will 
generally show such to be the fact. If there are well 
formed shreds stricture may be suspected and should 
be looked for at once. On the other hand, if there is 
no previous history of infection and the present condi- 



CHRONIC SPECIFIC URETHRITIS. 103 

tion is only of a few months' (3 or 4) duration, the 
small (lighter in weight) stringy substance indicates that 
at certain points in the canal there are spots of chronic 
inflammation (possibly extending into the submucous 
tissue and described by some authors as strictures of 
large calibre) which are causing more or less obstruction 
to the free passage of the urine and thus acting as a 
cause in keeping up the urethritis. Where stricture is 
found the condition must be treated according to the 
rules laid down for the care of this complication. No 
stricture being found, particular attention must be 
directed to the promotion of these inflammatory 
patches. 

One other truth is evident at times : in some cases 
patients are over-treated. This may be administered 
eirher internally in the shape of irritating drugs, or ex- 
ternally with hand injections (by the patient) or at the 
office by instruments, irrigations, etc., Where continued 
and appropriate measures seem only to keep the condi- 
tion at a standstill, in fact may render it slightly worse ; 
good results often follow a secession of any and all medi- 
cation, at least for a time (say from 4 to 8 weeks) when, 
if resolution is not complete, further treatment may be 
tried. 

THICKENED MEMBRANE. 

If the meatus is small it must be cut so as to admit 
at least a*No. 30 F. sound, which should be passed un- 



104 SIMLPE AND SPECIFIC URETHRITIS- 

der the same antiseptic precaution as though for the di- 
lation of stricture, immediately following it with a silver 
solution, but one point stronger than the one used pre- 
vious to the examination for the cause. Should this 
procedure seem to aggravate the condition it is well to 
discontinue a repetition of the same, but the injections 
of silver should be continued until the urine shows the 
condition to be improved over the former stop. If the 
urine shows great improvement as to clearness, about 
the fourth to sixth day, the same procedure should be 
repeated, increasing the silver in strength. At this time 
it may be well to give the canal a rest for two or three 
weeks, allowing nature to assist if possible in the absorp- 
tion of any exudate that may be left behind. One should 
keep in mind at all times what constitutes a cure, and the 
case must not be dropped until that end is attained. If, after 
the lapse of two or three weeks, the urine does not show 
the membrane to be in a condition as already described 
(see infection) sound treatment should be resumed and 
continued until such a time as it is safe to say there is 
no danger of infection. The much vaunted endoscope 
which conveys a light into the canal by aid of an elec- 
tric lamp is absolutely of no value in this condition ; in 
fact it does more harm than good and should not be 
used. 

GRANULATIONS. 

True granulation tissue is a condition that is not 
found very often ; yet occasionally an obstinate case 



CHRONIC SPECIFIC URETHRITIS. 105 

will show such to be the cause of continued trouble. 
Symptoms are often so well marked that one can with 
fair certainty name the cause, or if the electro-endoscope 
is at hand this will not only quickly decide the case but 
may be used to advantage for treatmant. Their loca- 
tion must be positively determined and silver used as 
the destructive agent. The canal should be thoroughly 
flushed with an antiseptic solution before placing the 
tube therein and not over a two per cent, solution 
used for the first application. This can be repeated 
about every four to seven days, according to the amount 
of irritation produced, the silver being increased up to 
ten per cent, if necessary. Where the electric light is 
not available the sound will accomplish the same pur- 
pose, only more slowly. The canal must be previously 
flushed and full-sized instrument used, every fourth day 
being followed by irrigation of silver in strength as for 
chronic inflammation of the whole membrane. Powders 
should never be used as they only tend to stimulate the 
already granulating surface. 




CHAPTER XVI. 

GHRONIG SPECIFIGURETHRITIS 

THE TREATMENT OF CHRONIC GONORRHEA, (CONTINUED.) 

STRICTURE. 

When stricture is positively located the canal should 
be restored to its normal calibre as soon as possible. In 
a great majority of cases this can be accomplished by 
graduated sounds, using all antiseptic precaution (see 
urinary infection page 77) and following the passage of 
these instruments by an astringent (see silver injection 
page 59). It will be rarely found the t cutting instilments 
are necessary, and especially is this true in that large 
percentage of strictures that are located in the deep ure- 
thra. As to the amount of dilation at each visit, every 
case should be treated on its own merits, noting care- 
fully the irritation produced the previous time. In re- 
cent conditions an increase of 3 to 5 numbers of the 
French scale, up to 30, will be followed by little or no 
inconveniences to the patient, whereas in an old tough 
stricture 2 or 3 numbers may be the maximum. Stric- 
ture should be considered almost like a rubber band, 
i. e , if it is not kept at the highest degree of dilation it 
will very soon retrace its steps and in time assume its 



CHRONIC SPECIEIC URETHRITIS. 107 

former condition ; in other words, dilation at the maxi- 
mum (average 30) should be continued until there is a 
complete absorption of the cicitritial tissue. When such 
a condition is attained is a much disputed question, 
some going so far as to say that stricture is never cur- 
able, excepting possibly by cutting. It is possible to 
say, almost with a certainty, when there is the least sign 
of new t.ssue present, when all cicitritial new formation 
has been entirely absorbed and stricture entirely gone, 
and in months or years afterwards to positively decide 
as to whether there is any reaction going on. The least 
pathological contraction is accompanied by new tissue 
formation, behind which there is an inflammatory zone, 
varying in degree according to the amount of obstruc- 
tion present. Stretching or dilating of this tissue is ac- 
companied by an exudation of a sort of hyaline material, 
both in proportion to the amount of dilation and also to 
the density of the contraction present. The exudation 
taking place at the site of contraction is deposited either 
directly in front or behind the latter where it comes in 
contact with the already described inflammatory zone, 
thus intermingling with any pus that may have remained 
after the primary cleansing of the canal, or cells which 
may have exuded between the antiseptic wash and the 
time of dilation. At the sight of inflammatory changes 
epithelium is constantly being thrown off and this will 
also be found. Therefore a positive indication of ure- 
thral contraction, due te new tissue formation, and 



108 SIMPLE AND SPECIFIC URETHRITIS. 

which has been stretched, is characterized by a small, 
bloody-like appearing string which the microscope shows 
to be composed of blood, pus and epithelial cells, en- 
twined in a hyaline structural body. As dilation is con- 
tinued, new tissue formation becoming less, this bloody 
string becomes smaller, disappearing entirely when the 
canal has reached its normal condition and contractions 
have entirely disappeared. This blood-like shred must 
not be confused with clots or even stringy clot forma- 
tions, so often seen after the passage of a sound. Blood 
may appear in the washings from forcible stretching, 
with possibly rupture of the meatus, fossa-navicularis, 
squeezing of old inflammatory spots, or the use of a 
sound too large for the normal urethra. It is not neces- 
sary in searching for a stricture to use an instrument 
over 20 to 24 F., for with the penis on the stretch the 
walls of the urethra will be brought so closely into appo- 
sition that either of the bougies mentioned will detect 
the least narrowing ; but even though this is possible, 
the meatus and navicular valve must be large enough to 
admit a No. 30 F. sound. Where treatment must be 
commenced with a filiform two or three of these instru- 
ments should be made to pass the obstruction if pos- 
sible, allowing them to remain in situ until the spasm 
which is always produced passes off and they can be 
removed without force. No unaided steel instrument 
should be passed through a urethra until a calibre of at 
least 18 or 20 F. is reached. Various authors advise 



CHRONIC SPECIEIC URETHRITIS. 109 

the use of rubber sounds after the filiform and until the 
steel instruments can be used of the aforementioned 
sizes. Rubber instruments of any kind or make are 
very unsatisfactory, for the moment a stricture is touch- 
ed it takes on a spasmodic condition (especially is this 
so of old ones) and even though the point of the instru- 
ment may become engaged it will be held so tightly that 
forcing it through is almost if not impossible in every 
case unless the sound (rubber) be of large size. This 
is obviated, the stricture gradually dilated and no pos- 
sible danger of a false opening being made if the fili- 
form is used as a guide and a tuneled catheter used as a 
sound until a calibre of 20 F. is reached. (Tunneled 
instruments should be at hand ranging in size from 5 F. 
to 20 F.) In using this procedure great care should be 
exercised lest the filiform be cut in two just anterior to 
the contraction. The physiological changes in dilated 
stricture should always be borne in mind, as it is the 
one great aid in telling when instrumentation should be 
resumed. After the passage of an instrument through 
an urethral stricture the following changes take place at 
about the times mentioned : 

First 36 hours, mechanical dilation. 

Next 48 to 50, physiological congestion, due to irrita- * 
tion produced. 

Next 38 to 60, absorption, until the previous dilation 
is reached, this being at about the beginning of the 6th 
or 7th day, when recontraction commences. With a rest 



110 SIMPLE AND SPECIFIC URETHRITIS. 

of say 24 hours, sound treatment should again be re- 
sumed and carried out as before, using careful judgment 
as to dilation as referred to elsewhere. After No. 30 
F. (average calibre of the normal urethra) is reached di- 
lations at weekly intervals should be continued until 
there is an entire disappearance of the bloody string 
heretofore alluded to, this necessitating 5 to 8 visits. 
Occasionally the bloody string insists upon reappearing, 
even after 8 successive dilations to 30 F. In that case 
we are in all probability dealing with a canal having a 
normal calibre of over 30 F., therefore sounds should be 
increased in size accordingly, when it will be generally 
found that 31 F. or 32 F. will produce the desired re- 
sult (absence of the bloody shred). Not only should 
there be a disappearance of the bloody shred, but the 
morning urine must be clear cf any and all debris. This 
latter is found to be the case long before the former is 
attained, and furthermore it may be conscientiously 
stated that the inflamed membranes (chronic specific 
urithritis) when complicated by stricture assume a nor- 
mal condition more quickly than when this complication 
is absent. 

Certain strictures call for division at once, but it is un- 
wise to even think of division until the urine is almost 
if not entirely clear, excepting possibly the shreds. Such 
conditions are : resilient, tough, fibrous, traumatic and 
where great irritation, some hemorrhage or chill always 
follows the passage of a sound. In all these cases the 



CHRONIC SPECIFIC URETHRITIS. 1 1 1 

perineum should be opened, as it facilitates drainage 
and often prevents trouble. As alluded to elsewhere, 
stricture tissue is very irritable and will spasmodically 
contract at the least interference or touch, but the lumen 
of the canal is never completely closed. Therefore 
where repeated attempts fail to effect an entrance cocaine 
5 c / locally or a general anesthetic will so relax any 
spasmodic action that one or two of these instruments 
can be passed through. ; When it is possible to pass a 
filiform or other instrument it is found at times that its 
full movement up or down is interfered with to such an 
extent that severe pain may be produced in attempting 
its withdrawal. In such a condition it is always well to 
leave the instrument in situ for io to 25 minutes, or un- 
til spasmodic action has passed away. When using 
filiforms if this rule is followed it will often be found 
that when one instrument is passed with much difficulty 
two or three, or even a tunneled sound can be slipped 
by quite easily. The fact should not be lost sight of 
that the opening in stricture is rarely in the center of 
the canal, and where there are two or more the opening 
through the first may be at the roof, where in the second 
it may be on the floor. For this reason the exploring 
point of a filiform should be bent at an angle of about 
45 degrees. 

NAVICULAR VALVE, SMALL MEATUS. 
When this valve (situated 1-4 of an inch behind the 



112 SIMLPE AND SPECIFIC URETHRITIS. 

meatus) is contracted so that any obstruction is offered 
to a No. 30 F. bulb it must be cut. If the meatus is 
small it can be divided at the same time, but neither of 
these structures should ever be enlarged beyond No. 30 
of the French scale. Division should always be made 
along the floor and either to one side or not quite up to 
the artery of the frenum. 

ANEMIA AND CONSTITUTIONAL CONDITIONS 

These two conditions are usually associated, one de- 
pending upon the other. Yet the first (anemia) may be 
present, due entirely to local conditions, such as the ad- 
ministration of copaiba or other drugs, plus the long 
continued suppuration. As copabia, cubebs, etc., are 
only of value in the second stage of gonorrhea these 
must be discontinued after that period. The dormant, 
gastro-intestinal absorbents should be revived before 
ordering hematics. Tr. nux vomica in 15 drop doses three 
times daily, in water, 30 minutes before food, gives most 
gratifying results. (Strychinine will not answer as a sub- 
stitute.) After its use for ten days or so iron should be 
given in 12 to 15 drop doses, in water, or it may be 
combined with nux vomica if thought necessary. A most 
excellent prescription, and one that has proven very ef- 
ficacious not only in the conditions just mentioned but 
in any and all cases where iron and nerve tonics are 
called for, is as follows : 



CHRONIC SPECIFIC URETHRITIS. 113 

Jfy Ferri pyrophosphate, grs. 50 

Tr. nux vomica, drs. 5 

FL ex. erythroxylon,* ozs. 1 

Elixer lactopeptine ad. ozs. 4 
M. Sig. One teaspoonful in water t i d, after food. 

Constitutional conditions, as tuberculosis, cancer, 
bright's disease, diabetes and syphilis, should be 
combatted by drugs appropriate to these diseases, in 
connection with all hygienic, dietary and other means 
known to be of advantage. Tubercular subjects should 
be advised to seek a change of climate, preferably that 
of Colorado, New Mexico, or Northern Texas, where 
they should reside out of doors as much as possible, of 
course avoiding such exercise as horseback riding or 
bicycling if the prostate or other adjacent organs are in- 
volved. One of the best drugs known is creasote vale- 
rinate which must be given continuously in from 3 to 10 
drop doses three times a day. Except in the anemic or 
certain, conditions, but little result will be obtained from 
drugs in Bright's disease. Here diet is all important. 
(See diet for nephritis.) The same may be said of dia- 
betes, excepting possibly that the main articles of food 
or drink absolutely contraindicated are those containing 
sugar or starches. Syphilis should receive attention ac- 
cording to the condition and stage present. 



•& Erythorxylon should not be used for over two continuous weeks, owing to 
*he fact that an appetite might be formed for this drug. 



CHAPTER XVII. 

CHRONIC SPECIFIC URETHRITIS 

THE TREATMENT OF CHRONIC GONORRHEA, (CONTINUED.) 

LITHEMIA. 

This condition must be combattcd by dietic, hygienic 
and medicinal measures. All drugs that in any manner 
might interfere with the perfect assimilation of food, 
such as copabia, cubebs, santalwood oil, etc., must be 
stopped. Foods, vegetables and liquids known to be 
rich in substances which cause excesses of uric acid, ox- 
alates, etc., such as red meat, (beefsteak and roast beef) 
shell fish (lobsters, clams, oysters, softshell crabs, etc.,) 
tomatoes, spinach, cucumhers, rhubarb, asparagus, and 
all malted liquors and high wines (it is inferred that the 
latter should not be used, lithemia or no) must also be 
avoided. In certain individuals tobacco has a tendency 
towards the production of phosphates, urates, etc., and 
when such is surmised to be a cause it should be dis- 
continued or allowed only to a very limited amount. 
Exercise (not fatigueing) systematic bathing (Turkish or 
cabinet is very beneficial if not indulged in too often), 
and plenty of refreshing sleep is all important and should 
be insisted upon. All meals should be of a nutritious 
character and must be taken at regular intervals. When 



CHRONIC SPECIEIC URETHRITIS. 115 

rheumatism is present, or there is a rheumatic tendency, 
this should receive careful attention. When, from 
some previous condition, malassimilation is present, 
heroic measures are often called for. A prescription 
which has given the author the best of results is as fol- 
lows : 

Jfy Acid nitro-hydrochloric dil, gtt. 15 
Pepsin gr. 2 

Tr. nux vomica gtt. 15 

Aq. menth, pip. ad. dr. 1 

Sig. To be taken with water, after food, three times 
daily. 

None of the many advised specifics for uric acid 
elimination can be advised as they all tend toward one 
end, a failure to produce the desired result. Possibly 
the best drug for this condition is lithia citrate, 10 grains 
in a glass of water three or four times a day. 

PROSTATIC OR VESICULAR INVOLVEMENT. 

Treatment of a chronically inflamed prostate (usually 
follicular variety in young subjects, where there has not 
been a previous acute parenchymatous condition,) must 
be carried out as carefully as that advised for inflamma- 
tion of the urethra, i. e., all measures tending towaid ir- 
ritation must be avoided. Although the inflammation 
involves the numerous ducts and sinuses, possibly as* 
far as the acini, it should be remembered that the over- 



116 SIMPLE AND SPECIFIC URETHRITIS. 

lying mucous membrane (posterior urethra) is also in- 
volved, and often to a greater extent than the latter. 
For this reason, urethral instrumentation should be 
avoided until the urine shows by its clearness that the 
membrane is either in a fairly normal condition or that 
the inflammation is at a standstill, due to some unknown 
cause. At this time stricture or contractions can be 
looked for and when found should receive attention at 
the same time as the prostate. The one aim of the sur- 
geon must be to promote absorption of the inflammatory 
exudate, and this is best accomplished by sounds (full 
size at once or as soon as possible), local, urethral and 
rectal, and by the use of the psychrophore. While the 
urethral condition is under treatment, rectal and internal 
measures may be used as these in no way seem to act 
in causing irritation. Heat to the prostate is one of the 
best and most important measures to be advised, but it 
must be applied in the moist form, and for this reason 
the Winternitz rectal instrument will not be considered. 
The apparatus for the application of moisture to the 
prostate and vesicles, described some time ago by Dr. 
Guiteras of New York, seems to fulfill every requirement 
and can be advised for this work. At least one gallon 
of normal salt solution at a temperature of 115 F. must 
be used every night before going to bed. Following 



The author has an instrument under construction whereby 4 to 6 fine jets of 
nonral salt solution a e hrcwn constantly against the prostate, keeping the rectum 
filled to a moderate extent and then passing out through one larger aperture, but 
owing to mislaid plans ill's has not been comple ed as yet. 



gtt. 


3° 


•40 


gr- 


5 




gr- 


IS 




g r - 


i 





CHRONIC SPECIEIC URETHRITIS. 117 

this, and while the rectal temperature is still high, a 
suppository of ichthyol and belladonna should be placed 
above the internal sphincter where it will rest against 
the prostate. The following is a formula which has 
given me much benefit : 

j$ Ichthyol 

Ex. belladonna 

Ex. hyoscymus 

Iodine 

M. et ft. rectal suppositories No. 15. 
Sig. Insert one before retiring. 

Excepting under well defined conditions (see the treat- 
ment of stricture before the urine has become entirely 
clear) no internal instrumentation should be attempted 
until the urine shows by the absence of pus that inflam- 
mation has entirely disappeared, except at a few local- 
ized spots, such being evidenced by well defined shreds 
(indicating contractions) small, flake- like pieces, consist- 
ing of pus cells, epithelium and possibly a few cocci, 
(localized inflammatory areas) or commoa-like plugs 
forced from the prostatic sinuses either by the urinary 
stream or by contraction of the bladder and prostate in 
its effort to expel all the urine. At this time sound 
treatment must be commenced, each instrument being 
preceded by an antiseptic and followed by an astr_ngent. 
The silvei solutions which have been used for the gen- 
eral inflammatory condition may be continued here and 



118 SIMLPE AND SPECIFIC URETHRITIS. 

if no irritation seems to arise as they are increased in 
strength, these may be carried up to the thousand mark, 
or even i in 500. Where stricture is present it must be 
dilated, the canal being brought to a normal calibre as 
soon as possible, but sounds must not be used less than 
5 to 6 days apart, on account of the irritation so often 
produced by these instruments. 

Nervoas symptoms accompanying chronic follicular 
prostatitis are at times distressing and very marked 
where the individual has a nervous tendency and the 
caput gallinaginis is involved. (See Firger's work on this 
subject.) Tonics must be given according to the condi- 
tions present, and at the same time some quieting drug 
for the nervous system. In my hands nothing has acted 
so well as Arsenauro, commencing with 5 drops in water 
three times daily, increasing one drop each day until fif- 
teen or twenty is reached. As it is quite impossible to 
say when the prostate is in a normal condition (from 
follicular inflammation) by examination per rectum, the 
urine and symptoms must be depended upon as our only 
aid in saying when the condition is normal, or as nearly 
normal as it is possible to bring it. All sensations re. 
ferrable to the prostatic region should be absent and the 
urine must be free of comma-like plugs. As the author 
has never received any benefit from massage this proce- 
dure will not be mentioned. When such is attained there 
may yet be a suspicion of pus being present in the acini 
which may only appear upon accumulating sufficiently 



CHRONIC SPECIFIC URETHRITIS. 119 

to cause the gland to contract, thus expelling it into the 
posterior urethra, or it may be forced out at the time of 
sexual intercourse, recourse must be had to methods 
which will cause an expulsion of the prostatic secretiom 
for examination. 

This maybe accomplished by advising intercourse, us- 
ing a condom, examining the same for pus (suppurative 
involvement of the urethra must be absent) and microor- 
ganisms, or after urinating and thorough flushing of the 
canal the prostate can be manipulated per rectum, bring- 
ing forth the exuded material by either forcing a few 
drops of urine or again flushing the urethra, allowing 
the solution to pass through the posterior portion, catch- 
ing it upon expulsion and examining it by use of centri- 
fuge and microscope. After the passage of a sound and 
withdrawal it is often seen (formel-glycero, formalde- 
hyde drops one, glycerin one ounce as the lubricant) 
that a small, whitish drop appears at the meatus. Al- 
though examination of this may throw some light on the 
desired question it cannot be regarded as very positive 
evidence, for the reason that the same process which 
takes place in the prostate (dilatation with a contraction 
and expulsion of contents) may occur in the urethral 
glands, and thus pus may be found. One other method 
may give favorable results, viz., previous injection of the 
anterior urethra with methylene blue sol., this being fol- 
lowed by any of the methods already alluded to. If the 
solution is retained in the anterior urethra, say for ten 



120 SIMPLE AND SPECIFIC URETHRITIS. 

minutes, anything in front of the compressor will be 
stained, when behind this muscle the reverse is the case. 
The only treatment of avail in this condition (follicular 
prostatitis) is the continued use of the moist heat, suppo- 
sitories, sounds and internal irrigation by silver, taking 
great care not to aggravate the condition by too frequent 
use of the latter. 

VESICULITIS. 

Tie older this condition the quicker will resolution be 
established. When an acute, or even a subacute condi- 
tion, rest, with quieting drugs, is all important. All 
forms of urethral medication must be stopped, the pa- 
tient placed in bed and suppositories containing opium 
used for the relief of pain and discomfort until the in- 
flammatory action has reached its acme and is on the 
decline. At this time the rectal douche becomes a very 
valuable adjunct, one gallon of salt solution being used 
at a temperature of 115 F. which should be followed by 
a suppository as in the treatment of chronic follicular 
prostatitis. (See formula, page 117 .) Urethral medica- 
tion may now be resumed and carried out as before the 
vesicular involvement. Where the trouble is very chronic, 
possibly of a year or more standing, the index ringer 
may be used to great advantage for emptying these sacs 
of their contents. In almost every case, at this time, it 
will be found that stripping is all that is necessary and 
that through emptying of the vesicles about every 48 



CHRONIC SPECIEIC URETHRITIS. 121 

hours for three or four times will be followed by com- 
plete resolution. As proof that there is an entire ab- 
sence of pus the contents of the condom may be exam- 
ined or the finger used as stated in chronic prostatic in- 
volvement. 

A few words of warning in regard to this condition, 
which had such an important place in genito-urinary 
literature some time ago, may not be amiss. There is 
no doubt but that the seminal vesicles are involved more 
often than they are credited with the same, but to charge 
these sacs as being the seat of inflammation in every 
case of chronic gonorrhea that does not respond to medi- 
cation is a great mistake. Furthermore, although at a 
certain time stripping is of great advantage and in real- 
ity the only possible mode ot evacuating the contents 
(coitus eliminated), yet, nevertheless, when this pro- 
cedure is practiced before every blood vessel is 
in a state of relaxation, due to chronicity, the finger 
or any mechanical device for forcing out their contents 
is damaging and will only prolong the existing condition. 
One of the most important aids in diagnosis of vesicul- 
itis is a history of the case, but as these organs lie in 
such close proximity to the prostate and posterior ure- 
thra, and the symptoms are so nearly alike, great care 
should be exercised lest vesiculitis be diagnosed when 
posterior urethra or prostate is the parts involved. 



CHAPTER XVIII. 

CHRONIC SPECIFIC URETHRITIS 

THE TREATMENT OF CHRONIC GONORRHEA, (CONTINUED.) 

FOLLICULITIS. 

Where follicles are known to be the direct cause of 
continued trouble no time should be lost in ascertaining 
their location and accomplishing their destruction. The 
urine must be entirely clear (shreds, prostatic plugs and 
floculent specs excepted) so that a normal field may be 
seen and the offending follicles found, these being usually 
located on the roof of the canal, about midway between 
the meatus and the compressor. (See electric lamp, 
tubes.) The optical attachment was made from the pre- 
scription furnished by Dr. J. J. Finerty and consists of 
a prism having a magnifying lens attached to the ante- 
rior surface. For the carrying of cotton as a swab, and 
also the silver solution, nothing acts so well as pieces of 
wood the size or thickness of a match and about eight 
inches in length, the one to be used as the silver carrier 
to be slightly pointed so as to enter the follicle. (These 
are to be destroyed after using.) As the mucous mem- 
brane passes under the end of the tube occasionally a 
small fold may be mistaken for a follicle, but this can be 
quickly recognized if a small probe (steel) is used. In 
the case of the former the probe will simply slip through 



CHRONIC SPECIFIC URETHRITIS. 



123 



this fold, whereas if a follicle is present the probe will 
enter it. Diseased follicles are generally easily recog- 
nized by their swollen, dark appearance in contradis- 
tinction to the surrounding normal membrane, which is 
usually of a pinkish hue. Follicles should be destroyed 
by a 20 per cent, silver solution, and if the trouble is 
due to this cause, per se, and they are all found, usually 
no further treatment is necessary. Many electric con- 

fig. 3. 




Otis Electric Lamp, with author's optical attachment. 



trivances are in the field for this work, but from quite 
an extended experience with various different devices 
the Otis lamp, with the author's attachment, can be ad- 
vised and recommended as one of the most valuable for 
this work. - The largest tube should be used which will 
enter the meatus, and when this may be smaller than 



124 SIMPLE AND SPECIFIC URETHRITIS. 

26 F. it is well to divide it to that number, or even 30 F. 
It should be remembered that although this is a very 
valuable instrument in its place its promiscuous use can- 
not be sanctioned for the reason that it may be the very 
cause for continuing irritation, thus aggravating the 
trouble. (See interference as a cause.) 

IDIOSYNCRASY. 

It is well that few individuals are peculiarly suscept- 
ible to catarrhal conditions of the urinary tract, for when 
such is the case the most careful and scientific care and 
advise seems to be of little or no value. In facial ap- 
pearance they resemble the Madonna type, well bdilt, 
large frame, muscles apparently well developed, features 
normal, the only seemingly defect being in the appear- 
ance of the skin. If closely scrutinized, one is struck 
with the peculiar white fineness, looking much like the 
anemic condition seen in young, fine-textured girls, 
(chlorosis, etc.,) excepting there is a want of that hag- 
gard, emaciated condition at times seen in some of the 
latter. In other words, there is a masculine appearance 
with the dernal texture of the female. These patients 
must not be confounded with those possessing, appar- 
ently, the same appearance as regards fineness of skin, 
for if carefully observed it is very evident from the care- 
worn, sunken eyes and general look of despair that they 
are suffering from some constitutional derangement 



CHRONIC SPECIFIC URETHRITIS. 125 

which is lowering the vitality, a pronounced anemia (See 
want of tone in the tissues.) Medicines seem to have 
little or no effect in these conditions, there seeming to 
be no direct cause which needs attention. Undoubted- 
ly the very best advice would be a change of climate 
with all that goes with it, but as we find few who can do 
this our aim should be from the start (acute infection) 
to prevent the development of that condition which is so 
prone to follow long continued suppuration, viz., want of 
tone in the tissue. The urine must receive the most 
careful attention, correcting any systemic defect discov- 
ered, such as lithemia, nephritis, nervous exhaustion, 
etc. The blood vessels should be kept under a constant 
state of contraction, at the same time fuel food being 
supplied to the system to take the place of tissue waste. 
The following has been found to be most serviceable 
from the moment of acute infection and must be con- 
tinued for at least six or eight weeks, if necessary: 

jfy Tr. nux vomica, oz. i 

Zinc phosphide, gr. i 

01. morrhue emulsion, ad. ozs. 16 

Sig. One tablespoonful t i d. 

In connection the diet must be the most nutritious 
avoiding only articles that are known to be detrimental 
to inflammation involving the genito-urinary tract. Of- 
fice injections seem to be foUowed by two results : one a 
diminution in the amount of discharge, with a clearing 



126 SIMLPB AND SPECIFIC URETHRITIS. 

of the urine, which in forty-eight hours after treatment 
is stopped relapses into its former condition (marked 
opacity and discharge), and secondly, no matcer what 
local medication or in what strength it is used, no bene- 
fit is apparent. Irritation must be avoided and unless 
there are positive evidences of a stricture due to former 
infection, (see page 45) instruments should never be al- 
lowed to enter the canal. From the author's experience 
with these cases the best results have been obtained by 
the continuous use of injections (such as zinc, etc., see 
page 92) by the patient himself. These injections must 
not be too strong (never over grs. 3 to the ounce) and 
should be used twice daily, or better still three times, for 
at least ten days after all discharge has stopped and the 
urine is fairly clear. Where injections have been con- 
tinued as above, for say at least two months, and yet a 
small amount of thin, watery discharge can be brought 
forward to the meatus and the urine passed in two glasses 
shows a slight turbidity in both, with the utmost care 
office injections may be given. (See treatment of thick- 
ened membrane, chronic inflammatory areas, page 103.) 
As the urine becomes clear, even though there may yet 
be a perceptible moisture at the meatus, sounds may be 
tried to aid in promoting absorption. Although it may 
not be necessary to continue the use of cod liver oil un- 
til entire recovery, nevertheless it should be taken for at 
least a month, after which a tonic of iron, arsenic and 
strychnine may be substituted and continued some time. 



CHRONIC SPECIFIC URETHRITIS. 127 

WANT OF TONE IN THE TISSUES. 
(See treatment of anemia, constitutional cachexia and 
idiosyncrasy.) 
Where a cause is discoverable this must be removed 
as far as possible. Avoiding exhaustion, outdoor exer- 
cise should be insisted upon, but late hours, loss of sleep, 
and undigestible food must be dispensed with. When 
there is evidence that gastro-intestinal secretion is dor- 
mant, food seeming not to be properly digested, appro- 
priate drugs should be given at the same time acting 
upon the patient's general condition by tonics, etc. (See 
Rx, page 113.) With the exception as noted (erythroxy- 
lon, page 113) such a prescription must be continued 
for some little time, or until the patient is in a good physi- 
cal condition. 

DIET AND GENERAL INSTRUCTIONS. 

In contradistinction to the treatment of acute specific 
urethritis, but little curtailment of diet or mode of daily 
life is necessary in chronic urethritis, excepting conditions 
as in lithemia or peculiar nervous conditions. Although it 
is not supposed that a constant diet of shell fish, aspar- 
agus and tomatoes would be allowed, yet unless there is a 
tendency towards lithemia, any of these may be taken in moder- 
ation. Tobacco is not contraindicated excepting in those con- 
ditions where through its use the nervous system is excited or 
injured. COITUS AND LIQUOR must never be allowed 
until resolution is complete. 



128 SIMPLE AND SPECIFIC URETHRITIS. 

SUMMARY. 

i. Chronic specific urethritis should be considered in- 
fectious until there is no discharge and the morning urine 
shows that the membrane is in a healthy condition. (It 
is assumed that there has been no vesicular or prostatic 
involvement.) 

2. The posterior urethra is involved in every case and 
must receive attention before a cure can be hoped for. 

3. Irritation is the one and great cause of continued 
trouble. This may be due to instrumentation or harsh 
treatment, let it be internally by drugs, etc., or externally 
by the use of bougies, sounds, endoscope, irrigations or 
deep injections. 

4. Never use an instrument in the urethra until the 
urine is clear, excepting possibly of shreds. 

5. The endoscope is rarely called for and should not 
be used unless positively indicated. 

6. Every case is a law unto itself and where continued 
local measures have failed it will often be found that had 
cod liver oil or other tonics been given a cure would 
have been obtained" sooner. 

7. Shreds are evidence of localized inflammation 
which must be removed, otherwise sooner or later cicatri- 
cal tissue will form and result in stricture formation. 

8. Always precede urethral instrumentation by an 
antiseptic and fellow with an astringent. 



CHRONIC SPECIFIC URETHRITIS. 129 

9. In searching for stricture nothing but a bulbous in- 
strument should be used; this must pass the compressor 
muscle, such being evidenced by the patient having the 
sensation of urination. 

10. The finding of a bloody string following dilation 
of the urethra is a positive sign that stricture, or new 
tissue formation, is present and has been dilated. Its 
continued absence indicates that a normal calibre has 
been reached and no pathological narrowing is present. 

11. With few exceptions (tuberculosis, cancer, etc.) all 
cases of urethral inflammation are curable. 

12. As symptoms are very deceiving every case should 
be examined from the meatus to the secreting portion of 
the kidney, the testicles included. 

13. The fact must not be forgotten that astringents act 
only on blood vessels in a relaxed condition, therefore 
no improvement should be looked for until every part 
of the membrane is in a chronic state of inflammation 
such being brought about by the avoidance of any irri- 
tation, either internal or external, and the lapse of time. 

THE FOLLOWING WILL HOLD GOOD IN EVERY CASE: 
THE OLDER THE CONDITION, THE QUICKER THE 
CURE. 



CHAPTER XIX. 

APPARATUS NECESSRARY FOR THE DIAG- 
NOSIS AND TREATMENT OF PATH- 
OLOGICAL CONDITIONS OF 
THE URINARY TRACT. 

6 Test tubes, 

i Wash bottle. 

3 Wine glasses (capacity 6 to 8 drachms.) 

i Urinometer. (Squibbs.) 

i Ureaometer, (Doremus.) 
Litmus paper, blue and red. 

2 Funnels, glass. 

i Graduate, 4 oz. 

3 Watch glasses. 
Several droppers. 

1 Pipette graduated to 10 c.c. 

1 Pipette ungraduated. 

2 Glass rods. 

1 Alcohol lamp. 

Cocaine, 4% solution. 

Filter paper. 
1 Albuminometer. 



WORKING APPARATUS. 131 

MICROSCOPICAL. 

Microscopical stand with eye pieces, (Spencer.) 
i-6th 2-3rd dry, and i-i2th oil immersion objectives. 
Abbe condenser, hemacytometer, (Thoma-Ziess.) 
Slides, cover glasses, Japanese paper, Canada balsam, 
cedar oil, platinum hook, pinch forceps. 
Centrifugal machine with attachment for urine and blood. 
Methylene blue, (Loeffler's solution) for gonococci. 
Carbol Fuchsin solution, for tubercle bac. 
Gentian violet solution. 
Nitric acid 25% solution. 
Alcohol 95% solution. 
Stains for Gram's method. 

CHEMICAL. 

Nitric acid c. p., nitric acid commercial, acetic acid c. p., 

acetic acid 50% solution. 

Tyson's alkaline solution. 

Fehling's solution. 

Haines's solution, for sugar. 

Whitney's reagent, for sugar. 

Sat. sol. Sodium chloride. 

Distilled water. 

Sodium hydrate solution, for urea. 

Bromine, for urea. 



132 WORKING APPARATUS. 

URETHRAL DIAGNOSIS AND TREATMENT. 

Ultzmann's syringe with author's attachment (page 80.) 

Zinc-alum solution, Silver nitrate solution 20% as a base. 

Formaldehyde. 

Steel sounds up to 32 F. 

Filiforms, on 2 dozen. 

Tunnelled sounds up to 20 F. 

Bougie a boule up to 30 F. 

Meatotomy knife. 

Deep urethral catheter with syringe, capacity 2 drs. 

Circumcision forceps (Fisher.) 

Prostatic douche (Guiteras.) 

Electric lamp (Otis-Dowd.) 

Wooden rods (See page 122.) 

Endoscopic tubes 20, 24, 30, F. (Klotz.) 

Endoscopic tube 30 F. (Lydston.) 

Author's spray catheter. 

Urethrotome (Otis.) 

Retractors. 

Perineal tube 

Knives, several different shaped blades. 

Speculum urethral. 

Lithotomy staff. 

Kelly pad. 



WORKING APPARATUS. 133 

Groved directors. 

Formic-glycero. (formaldehyde i, glycerine iooo parts.) 

Hypodermic syringe. 

Aspirator with several needles. 

Trochars. 

Needles, holder, silk and catgut. 

Artery forceps, one dozen. 

Vulselm forceps. 

Scissors, curved and straight. 

Curetts. 

SOLUTIONS FOR URINARY ANALYSIS AND THE STAINING 
OF BACTERIA. 

Tyson's alkaline solution. 



Magnesium sulfate, 




Aq. ammonia, 




Ammonium chloride, 


aa i part 


Water, 


8 parts. 


Fehling's solution. 




a. Cupric sulfate, 


34.636 gi 


Distilled water, 


ad 1000 c.c. 


b. Sodii-pot.tart. 


i73 



Sodium hydrate, (sp. g. 1120) 500 grms. 

Distilled water. ad 1000 c.c 

To be kept in separate bottles. When testing for sugar 



gr- 


3° 


oz. 


1-2 


oz. 


1-2 



734 WORKING APPARATUS. 

use equal parts of each. (See special works for the de- 
tection of glucose 

Haines's solution, for sugar : 

Copper sulphate, 

Water, dist. 
Make a perfect solution and add 

Glycerine, 
Again mix and then add 

Liquor potassia, ozs. 5 

Use 1 drachm of solution, boil and add 7 or 8 drops of 
suspected urine ; again boil and if sugar is present there 
will be a yellowish red precipitate found, which soon 
falls to the bottom of the tube.* 

Doremus' solution : 

Sodium hydrate, ozs. 6 

Water, pints 1 

Keep in well corked bottle in a dark place. 

Lceffler's Methylene blue, solution for gonococci : 
Saturate alcoholic sol. Methylene blue 30 c. c. 
Caustic potash sol. 1-10000 roo c. c. 

Use full strength. 



■5C- The writer has found that when there is but little sugar present, often as 
much as 30 drops of urine is necessary for its detection. 



WORKING APPARATUS. 135 

Carbol Fuchsin solution, for tubercle baccili: 

Fuchsin, grms i 

Alcohol c. c. 10 

Distilled water, c. c. ioo 

Carbolic acid cryst. grms 5 

Make a perfect solution. 
Gram's stains. 

Ehiiich's anilin water-gentian-violet solution. 

100 c. c. anilin-water (5 c. c. anilin oil to 100 c. c. of 

water) after being filtered toncc, alcoholic solution. 

of gentian violet. 
Gram's solution of iodine, (iodine, 1 part, pot. iod. 2 

parts, water 250 parts.) 
Method of using Gram's stain : 

Prepare slide in usual way, and after fixing cover the 
same with Ehrlich's aniline gentian violet solution (use 
no heat.) Staining lakes place at once. Remove stain 
by washing and cover specimen with Gram's iodine 
solution for half a minute or so. Now wash in alcohol 
until no more color comes away and then in water (fil- 
tered) several times. Counter stain with Bismarck 
brown, remove the excess with water and mount. Gon- 
ococci are stained brown where other diplococci are 
stained blue. 



INDEX. 



PAGE. 

Albumen in the urine ' 4 

Alcohol as a causative factor in urethritis 53 

Alkaline urine 5 

Alkaline solution, Tyson's 133 

Ammonio-magnesium-phosphate 8 

Amourphous phosphates 8 

Amount of urine in 24 hours 1 

Anemia, treatment of 112 

xlnemia as a complication chronic spec, urethritis 48 

Antiseptics necessary in urethral instrumentation 130 

Apparatus necessary for genito-urinary work 130 

Ardor-urine in simple urethritis 30 

Astringents in chronic specific urethritis 92, 100, 99 

Author's urinary examination chart 1 

B 

Bacilli in the urine 16 

Bacillus coli communis 77 

Bacteria in the urine 17 

Bactei ia, normal urethra 27 

Bacteria streptococci 72 



XX INDEX. 

Bacteria, staphylococci 85 

Bacteria, gonococci 97 

Bacterial decomposition 18 

Bacteriuria 17 

Balsams in urethritis 48, 53, 114 

Bathmg in urethritis 114 

Bichforide in urethritis 33 

Blood, appearance in the urine. '-.15? 72, 73 

Blood in the urine - 14, 72, 73 

Blood in tne urine, significance of 15 

Carpenter's classification of epithelium 12 

Corbol. fuchsin solution for tubercle bacilli 135 

Casts 11 

Casts, classification 

Casts, significance of .... 11 

Catheter in urethral or bladder work 79 

Causes of chronic specific urethritis 37 

Causes of simple urethritis 19 

Chemical examination of the urine 4 

Chills accompanying urethral instrumentation.... 82 

Chlorides 7 

Chronic urethral disease as a predisposing cause 

of gonorrhea Introduction 

Chronic specific urethritis 37 

•' " " when established 91 

" " " causes of 41 



INDEX. XXI 

Chronic specific urethritis, clinical indications of 59 

" definition of 37 

" " " diagnosis of 64 

" " •' infectiousness of 70 

" " '■ prognosis, in 75 

" " " synonyms, of 37 

" " " summary, of 128 

" " " treatment of 70 

Colon bacillus 20 

Constitutional debility as a cause of chronic spe- 
cific urethritis 49 

Constitutional debility, treatment of . 112 

Contraction of navicular valve as a cause of 

chronic specific urethritis 48 

Contraction of navicular valve, treatment of. 48 

Consistency of discharge in chronic specific ure- 
thritis 56 

Copabia in urethritis 48, 53, 114 

Coitus as a caufe of chtonic specific urethritis.... 49 

Copabia and cubebs in urethritis ..48, 53, 114 

Cowper's gland, secretion 69 

Crystals,..., 8 

" oxalates... 9 

" phosphates 8 

" uric acid 10 

Cubebs in urethritis. ....48, 53, 114 

Cure of urethritis, when complete 104 



XXII INDEX. 



Debility as a cause of chronic specific urethritis.. 49 

Definition of chronic specific urethritis 37 

" simple urethritis 19 

Diagnosis of chronic specific urethritis 63 

Diabetes, diet, etc., in chronic specific urethritis. 5 

Discharge at stool and after urine 61, 63 

Doremus sol. (for urea) 134 

Drugs to promote the elimination of uric acid 115 

Drugs as urinary antiseptics 81 



E 



Early and persistent interference 101 

Earthy phosphates 8 

Epithelium 12 

" classified 13 

" location . . . . . 12 

Pyelitis 72, 73 

Endoscopy 1 04 

" in treatment 105 

Exacerbations of chronic speific urethritis 40, 47 

Explanation plate I 26 

" n 73 

" in 84 

" IV 9 6 



INDEX XXIII 



Fehling's solution 183 

Fission fungi 17 

Folliculitis as a cause of chronic spec, urethritis. 55 

" recognition of diseased follicles 123 

' ' treatment of 122 

Foods to be avoided in chronic specific urethritis 114 



Gleet 37 

Glucose 5 

Gonococcus 96 

" staining for 9 

Gonorrhea in the male 37 

Gonorrheal shreds ,. 40, 45 

Gram's staining 135 

Granular urethritis 44 

Granulations as a cause of chronic specific ure- 
thritis \ 44 

Granulations, treatment of 104 

Growth of stricture 102 

H 

Haines's solution (for glucose) 134 

Hematuria 14 

Hippuric acid 6 



XXIV INDEX. 

I 

Idiosyncrasy as a cause of chronic specific ure- 
thritis 56 

Idiosyncrasy, treatment of 124 

Indican in the urine 6 

Indoxyl 6 

Injections in chronic specific urethritis 92 

" simple urethritis 22 

Instrumental infection in simple urethritis 23 

" " chronic specific urethritis 23 

Interference as a cause of chronic spec, urethritis 45 

Internal medication 112 

Irritation as a cause of chronic specific urethritis 45, 90 



Leucocytes 14 

Leucorrhea as a cause of chro. specific urethritis 25 

Lime, cryst aline 9 

Lithemia as a cause of chronic specific urethritis. 52 

" treatment of 114 

Littre's glands, secretions from 69 

Local medication in simple or chronic specific 

urethritis 99 

Localized inflammatory areas as a cause of 

chronic specific urethritis 103 

Loeffler's solution (for staining the gonococci)... 134 



INDEX. XXV 

M 

Meatus, small as cause of chronic spec, urethritis 48 

Menstruation 4 

Method of using Ultzmann-Dowd syringe 95 

Microbic invasion 77 

Micrococci urinae 18 

Microscopical examinaiion of the urine 8 

Molds 17 

Mucus corpuscles. 14 

Mucus cylinders 18 

Mucus in the urine .. 15 

Navicular valve as cause of chron. spec, urethritis 48 

" " the treatment of in 

Xeogerath's views 19 

Nephri tis 4 

" indications of 11,12 

Neuralgic pains in the testicles 60 

Neuroses in chronic specific urethritis 63 

Nisser, gonococcus of 96 

Nitrogen in the urine 6 

Non-specific urethritis.. 19 

Non-virulent urethritis 19 

Normal urethral cocci 27 

Nozzle of syringe, for use in injecting 3$ 



XXVI INDEX. 

O 

Odor of urine 3 

Opacity of urine 4 

Otis' opinion of gonorrhea 37 

Otis electric lamp— author's optical attachment... 123 

Oxalate of lime 9 

Overtreatment of urethritis 103 

p:i 

Pelvic epithelium 13 

Phimosis and periphimosis 61 

Phosphates ., 8 

" calcium 8 

" triple 8 

Physiology of urination 63 

Prognosis, chronic specific urethritis 75 

Prostatic or vesicular involvement as a cause of 

chronic specific urethritis 59 

Prostatic or vesicular involvement, treatment of.. 115 

" epithelium 13 

" plugs 60 

Prostatorrhea 69 

Posterior urethral involvement 94 

Pseudo gonococci 31 

Pus, appearance 14 

Pus in urine 13, 5 



INDEX. XXVII 

Pus in pyelitis 14, 72, 73 

Pus confounded with , 14 

R 

Rational treatment of chronic specific urethritis.. 90 

Reaction of urine 3 

Red blood corpuscles 15 

Relation of syphilis to gonorrhea 90 

Renal albuminuria n 

" calculi 10, 11 

' ' epithelium 13 

Rheumatism a cause of continuation of urethritis 54 



Santalwood oil in urethritis , 48, 53, 114 

Sediment in urine 8 

Semen in the urine ^8 

Shreds in the urine 40, 45, 93 

Silver injection in chronic specific urethritis 99 

Simple urethritis 1* 

11 cause of 19 

" diagnosis of 31 

" infectiousness of..... 70 

11 symptoms of 29 

" treatment of 43 

Specific gravity of the urine 2 



XXVIII INDEX. 

Spermatozoa 6 

Staphylococci 85 

Streptococci 72 

Stricture as a cause of chronic specific urethritis.. 45 

" diagnosis of , 107 

" rubber sounds in treatment of 109 

" filiforms in treatment of 109 

" treatment of 106 

11 changes taking place in, after dilation... 109 

" cutting operations no 

Sugar (glucose) 15 

Summary of simple urethritis 36 

" chronic specific urethritis 128 

Symptoms of chronic specific urethritis 59 

" simple urethritis 29 

Syphilis in relation to urethritis 50 

T 

Testicular neuralgia 60 

Thickening of mucous membrane as a cause of 

chronic specific urethritis 43 

Thickening of mucous membrane, treatment of... 103 

Tobacco in chron ic specific urethritis 114 

Transparency of urine 4 

Treatment of chronic specific urethritis 90 

" " " when to commence 91 

" simple urethritis ^ 



INDEX XXIX 

Triple phosphates 8 

Tripper f aden 46 

Tube casts n 

Tubercle bacilli , 16 

Tuberculosis as cause of chronic spec, urethritis. 49 

Tubercular cystitis 80 

Two glass test in examination of urine 60 

Typhoid bacilli 17 

Tyson's alkaline solution........ 133 

u 

Ultzmann syringe— author's attachment 80 

Urethral epithelium 13 

" antisepsis 77 

Urethritis, varieties of 19, 37 

" cause of 41 

" chronic specific 37 

" diagnosis of 64 

history of 88 

" m infectiousness of 70 

" prognosis of 75 

" symptoms of 59 

" urinary infection in 77 

" virulent 19 

Urethorrhea 68 

Urethroscope 55, 123 

Uric acid as a cause of chronic specific urethritis 51, 52 



XXX INDEX. 

Uric acid, colorless crystals 10 

Urine as a diagnostic agent in chronic specific 

urethrit is 60 

Urine 1 

" acidity of. 3 

" albumin in..... 4 

" amount of 1 

" blood in 14 

" casts in 11 

" Chlorides in 7 

" color of 3 

" epithelium in 12 

" fermentation of 17 

" general consideration of 1 

" leucocytes in 14 

1 ' microscopical examination of 8 

" nitrogen in . 6 

11 odor of 3 

" opacity of 4 

" oxalates in 9 

" phosphates in 8 

" pus in 13 

" quantity of..... 1 

" reaction of 3 

" sediment in 8 

" specific gravity of 2 

" spermatoza in 16 

" sugar in 5 



INDEX. XXXX 

Urine, transparency of 4 

" urea in 6 

" uric acid in 1 

u 

Vaginal bacteric 25 

Vaginitis 25, 51 

u gonorrheal 51 

" complicated with syphilis 51 

Varieties of urethritis 19 

Vegetations, warts 61 

Vesicle calculi 10, 11 

Vesiculitis as cause of chronic specific urethritis 54 

" treatment of 120 

w 

Want of tone in tissue as a cause of chronic spe- 
cific urethritis 57 

Want of tone in the tissue, treatment of 127 

White blood corpuscles (see leucocytis) 14 

Y 

Yeast fungi 17 

z 

Zinc injection, by patient 92 

Zinc-alum solution 99 

" " when to use 100 



June - 25 . 1«X>1 



JUN 18 1901 



->. - . ■ 







■■■■■■'■ : ■'*..■■■ . 






NG« 



ram 



■1^ si § fisHHHHi 




sSBHHfl Us 



